from docx import Document
from docx.shared import Pt, RGBColor, Inches
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests
import os

doc = Document()

# Page margins
from docx.shared import Cm
section = doc.sections[0]
section.top_margin = Cm(2)
section.bottom_margin = Cm(2)
section.left_margin = Cm(2.5)
section.right_margin = Cm(2.5)

# Default style
normal_style = doc.styles['Normal']
normal_style.font.name = 'Arial'
normal_style.font.size = Pt(11)

# Heading styles
for i in range(1, 4):
    h = doc.styles[f'Heading {i}']
    h.font.name = 'Arial'

# ── Helper functions ──────────────────────────────────────────
def add_heading(text, level=1, color=None):
    p = doc.add_heading(text, level=level)
    if color:
        for run in p.runs:
            run.font.color.rgb = RGBColor(*color)
    return p

def add_para(text, bold=False, size=None, space_before=0, space_after=4):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = bold
    if size:
        run.font.size = Pt(size)
    p.paragraph_format.space_before = Pt(space_before)
    p.paragraph_format.space_after = Pt(space_after)
    return p

def add_bullet(text, level=0):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.25 * (level + 1))
    run = p.add_run(text)
    run.font.size = Pt(11)
    return p

def add_table(headers, rows, col_widths=None):
    table = doc.add_table(rows=1 + len(rows), cols=len(headers))
    table.style = 'Table Grid'
    # Header row
    hdr_cells = table.rows[0].cells
    for i, h in enumerate(headers):
        hdr_cells[i].text = h
        for para in hdr_cells[i].paragraphs:
            for run in para.runs:
                run.bold = True
                run.font.size = Pt(10)
        # Header background
        tc = hdr_cells[i]._tc
        tcPr = tc.get_or_add_tcPr()
        shd = OxmlElement('w:shd')
        shd.set(qn('w:val'), 'clear')
        shd.set(qn('w:color'), 'auto')
        shd.set(qn('w:fill'), '1F4E79')
        tcPr.append(shd)
        for para in hdr_cells[i].paragraphs:
            for run in para.runs:
                run.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
    # Data rows
    for r_idx, row_data in enumerate(rows):
        row_cells = table.rows[r_idx + 1].cells
        for c_idx, cell_text in enumerate(row_data):
            row_cells[c_idx].text = cell_text
            for para in row_cells[c_idx].paragraphs:
                for run in para.runs:
                    run.font.size = Pt(10)
        # Alternate row shading
        if r_idx % 2 == 0:
            for cell in row_cells:
                tc = cell._tc
                tcPr = tc.get_or_add_tcPr()
                shd = OxmlElement('w:shd')
                shd.set(qn('w:val'), 'clear')
                shd.set(qn('w:color'), 'auto')
                shd.set(qn('w:fill'), 'D6E4F0')
                tcPr.append(shd)
    return table

# ── COVER ─────────────────────────────────────────────────────
p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run('MS GENERAL SURGERY — EXAM NOTES')
run.bold = True
run.font.size = Pt(18)
run.font.color.rgb = RGBColor(0x1F, 0x4E, 0x79)

p2 = doc.add_paragraph()
p2.alignment = WD_ALIGN_PARAGRAPH.CENTER
run2 = p2.add_run('Hydatid Cyst of Liver (30-Mark Question)')
run2.bold = True
run2.font.size = Pt(14)
run2.font.color.rgb = RGBColor(0x2E, 0x75, 0xB6)

p3 = doc.add_paragraph()
p3.alignment = WD_ALIGN_PARAGRAPH.CENTER
run3 = p3.add_run('Sources: Maingot\'s Abdominal Operations | Bailey & Love 28th Ed. | Sabiston Textbook of Surgery')
run3.italic = True
run3.font.size = Pt(10)
run3.font.color.rgb = RGBColor(0x70, 0x70, 0x70)

doc.add_paragraph()

# ── QUESTION STEM BOX ─────────────────────────────────────────
p_q = doc.add_paragraph()
run_q = p_q.add_run('EXAM QUESTION: "Write surgical anatomy of liver, enumerate functions of liver. Life cycle of E. granulosus, Clinical presentation, management and complications of Hydatid Cyst of Liver."   [30 Marks]')
run_q.bold = True
run_q.font.size = Pt(11)
run_q.font.color.rgb = RGBColor(0x7B, 0x22, 0x00)
p_q.paragraph_format.space_after = Pt(10)

doc.add_paragraph()

# ═══════════════════════════════════════════
# SECTION 1 — SURGICAL ANATOMY OF LIVER
# ═══════════════════════════════════════════
add_heading('1. SURGICAL ANATOMY OF LIVER', level=1, color=(0x1F, 0x4E, 0x79))

add_para('TIP: Draw Couinaud\'s segmental anatomy diagram — earns easy marks.', bold=True)

add_bullet('Largest solid organ; weight 1,200–1,500 g')
add_bullet('Covered by Glisson\'s capsule (fibrous peritoneal layer)')
add_bullet('Surface anatomy: Right lobe (larger) + Left lobe divided by falciform ligament')

add_heading('Couinaud\'s Segmental (Functional) Anatomy', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Liver divided into 8 independent segments')
add_bullet('Each segment has its own portal pedicle (portal vein + hepatic artery + bile duct) and hepatic venous drainage')
add_bullet('Segments I–IV = Left liver; Segments V–VIII = Right liver')
add_bullet("Cantlie's line = gallbladder fossa to IVC = true anatomical midline of liver (NOT the falciform ligament)")
add_bullet('Basis of anatomical/segmental hepatic resections')

add_heading('Blood Supply', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Portal vein: 75% of blood flow, 50% of oxygen supply')
add_bullet('Hepatic artery (branch of coeliac axis): 25% of flow, 50% of oxygen supply')
add_bullet('Hepatic venous drainage: 3 hepatic veins drain into IVC')
add_bullet('Biliary drainage: Right + Left hepatic ducts → Common hepatic duct at porta hepatis')

add_heading('Functions of Liver', level=2, color=(0x2E, 0x75, 0xB6))
add_table(
    ['Category', 'Functions'],
    [
        ['Metabolic', 'Gluconeogenesis, glycogen storage, fatty acid oxidation, urea synthesis'],
        ['Synthetic', 'Albumin, clotting factors (I, II, V, VII, IX, X, XI), fibrinogen'],
        ['Detoxification', 'Drugs, ammonia, bilirubin conjugation and excretion'],
        ['Immune', 'Kupffer cells (resident macrophages) — filter portal blood'],
        ['Storage', 'Vitamins A, D, B12; iron (ferritin); glycogen'],
        ['Excretory', 'Bile production (600–1000 mL/day)'],
    ]
)
doc.add_paragraph()

# ═══════════════════════════════════════════
# SECTION 2 — LIFE CYCLE
# ═══════════════════════════════════════════
add_heading('2. LIFE CYCLE OF Echinococcus granulosus', level=1, color=(0x1F, 0x4E, 0x79))

add_para('Hosts:', bold=True)
add_bullet('Definitive host: Dog (and other carnivores)')
add_bullet('Intermediate host: Sheep, cattle, swine (and ACCIDENTAL — humans)')
add_para('KEY POINT: Humans are accidental intermediate hosts — dead-end hosts. No human-to-human transmission.', bold=True)

doc.add_paragraph()
add_para('Life Cycle Steps:', bold=True)

steps = [
    '1. Adult tapeworm lives in the proximal small intestine of the DOG, attached by hooklets to the mucosa',
    '2. Eggs (oncospheres) are released and excreted in dog feces into the environment',
    '3. Sheep/intermediate host ingests the ova while grazing on contaminated ground',
    '4. In the duodenum, the egg loses its chitinous layer → Hexacanth embryo (oncosphere) is released',
    '5. Oncosphere penetrates the intestinal wall → enters portal circulation',
    '6. Liver acts as the FIRST FILTER — 50–75% of oncospheres lodge here; 25% reach lungs; 5–10% reach other organs',
    '7. In the liver, oncosphere develops into a hydatid cyst: grows 1 cm in first 6 months, then 2–3 cm per year',
    '8. Definitive host (dog) eats viscera of infected intermediate host → protoscolices evert, attach to intestinal mucosa → mature into adult tapeworm (6–7 weeks)',
    '9. Human infection = accidental: contact with dog feces, or ingestion of contaminated water/vegetables',
]
for s in steps:
    p = doc.add_paragraph(style='List Number')
    p.add_run(s).font.size = Pt(11)

doc.add_paragraph()

# Try to download and embed life cycle image
img_url = 'https://cdn.orris.care/cdss_images/0f1220be868b7734f985db87a0022599bf2aa7a73eefe69c5c28e56a98b26b68.png'
img_path = '/tmp/workspace/ms-surgery-notes/lifecycle.png'
try:
    r = requests.get(img_url, timeout=15)
    if r.status_code == 200:
        with open(img_path, 'wb') as f:
            f.write(r.content)
        doc.add_picture(img_path, width=Inches(5.5))
        last_paragraph = doc.paragraphs[-1]
        last_paragraph.alignment = WD_ALIGN_PARAGRAPH.CENTER
        cap = doc.add_paragraph('Figure: Life cycle of Echinococcus granulosus (Maingot\'s Abdominal Operations)')
        cap.alignment = WD_ALIGN_PARAGRAPH.CENTER
        cap.runs[0].italic = True
        cap.runs[0].font.size = Pt(9)
except Exception as e:
    add_para(f'[Life cycle diagram — see Maingot\'s Fig. 43-8]', bold=False)

doc.add_paragraph()

# ═══════════════════════════════════════════
# SECTION 3 — CYST STRUCTURE
# ═══════════════════════════════════════════
add_heading('3. PATHOLOGY — CYST STRUCTURE (Three-Layer Wall)', level=1, color=(0x1F, 0x4E, 0x79))

add_table(
    ['Layer', 'Name', 'Key Features'],
    [
        ['Outermost', 'PERICYST (Host layer)', 'Fibrous adventitial reaction; contains bile ducts + blood vessels; explains biliary and hemorrhagic complications; calcifies over time'],
        ['Middle', 'LAMINATED MEMBRANE (Ectocyst)', 'Bluish-white, gelatinous, ~0.5 cm thick; chitinous, acellular; acts as bacterial barrier and protein ultrafilter'],
        ['Innermost', 'GERMINAL LAYER (Endocyst)', '10–25 μm thick; produces hydatid fluid, brood capsules, scoleces, daughter cysts; "Hydatid sand" = 400,000 scoleces/mL'],
    ]
)
doc.add_paragraph()
add_bullet('Daughter cysts = endogenic vesiculation; a defense reaction to injury')
add_bullet('75% of lesions are single; 80% located in the RIGHT lobe')
add_bullet('Cyst grows slowly; often very large at presentation')

doc.add_paragraph()

# ═══════════════════════════════════════════
# SECTION 4 — CLINICAL PRESENTATION
# ═══════════════════════════════════════════
add_heading('4. CLINICAL PRESENTATION', level=1, color=(0x1F, 0x4E, 0x79))

add_para('Most cysts are ASYMPTOMATIC for years (slow growth). Symptoms arise from mass effect or complications.', bold=False)
doc.add_paragraph()

add_heading('Symptoms', level=2, color=(0x2E, 0x75, 0xB6))
add_table(
    ['Symptom', 'Notes'],
    [
        ['RUQ pain/heaviness (70%)', 'Mass effect from slow-growing cyst'],
        ['Palpable RUQ mass', 'Very common at presentation'],
        ['Jaundice', 'Biliary communication or extrinsic compression of bile ducts'],
        ['Fever', 'Secondary bacterial infection of cyst'],
        ['Urticaria / pruritus', 'Antigenic leak through cyst wall'],
        ['Anaphylactic shock', 'Sudden cyst rupture — EMERGENCY presentation'],
        ['Cough / haemoptysis', 'Hepato-bronchial fistula formation'],
    ]
)
doc.add_paragraph()

add_heading('Signs', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Hepatomegaly (smooth, non-tender)')
add_bullet('Hydatid thrill (fremitus) — pathognomonic but rare')
add_bullet('Jaundice in complicated cases')

add_heading('Epidemiology Clues', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Farming background; contact with dogs')
add_bullet('Endemic: Mediterranean, South America, Middle East, India, Australia, New Zealand')

doc.add_paragraph()

# ═══════════════════════════════════════════
# SECTION 5 — INVESTIGATIONS
# ═══════════════════════════════════════════
add_heading('5. INVESTIGATIONS / DIAGNOSTIC MODALITIES', level=1, color=(0x1F, 0x4E, 0x79))

add_heading('Laboratory', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Eosinophilia in ~35% (mild, 5–15%)')
add_bullet('Elevated bilirubin if biliary involvement')
add_bullet('LFTs generally normal unless complicated')
add_bullet('Casoni skin test (historical) — now replaced by serology')

add_heading('Serology', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('ELISA — most sensitive (80–100%)')
add_bullet('Indirect hemagglutination test')
add_bullet('Immunoelectrophoresis (arc 5 band) — highly specific')
add_bullet('Western blot — confirmatory')

add_heading('Imaging', level=2, color=(0x2E, 0x75, 0xB6))
add_para('1. Ultrasound (USG) — Investigation of Choice (first-line); specificity ~90%', bold=True)

add_para('Gharbi Classification (on USG):', bold=True)
add_table(
    ['Type', 'Appearance'],
    [
        ['Type I', 'Pure fluid collection'],
        ['Type II', 'Fluid + split wall (floating membrane — "Water Lily Sign")'],
        ['Type III', 'Fluid + septa (honeycomb/multivesicular)'],
        ['Type IV', 'Heterogenous echographic pattern (no clear cyst)'],
        ['Type V', 'Reflecting thick walls with calcification'],
    ]
)
doc.add_paragraph()

add_para('WHO/CE Classification (Bailey & Love):', bold=True)
add_table(
    ['Stage', 'Description'],
    [
        ['CL', 'Unilocular anechoic lesion, no internal echoes'],
        ['CE1', 'Anechoic with "hydatid sand"'],
        ['CE2', 'Multivesicular, honeycomb/rosette — daughter cysts'],
        ['CE3a', 'Detached laminated membrane ("Water Lily Sign")'],
        ['CE3b', 'Daughter cysts in solid matrix'],
        ['CE4', 'Inactive, mixed echogenicity — "bag of wool"'],
        ['CE5', 'Calcified wall — inactive/dead cyst'],
    ]
)
doc.add_paragraph()

add_para('2. CT Scan — Best for operative planning', bold=True)
add_bullet('Thick-walled cyst with daughter cysts and septa')
add_bullet('Exact depth within liver; relationship to IVC and portal vein')
add_bullet('50% show wall calcification; mandatory before laparoscopic surgery')

add_para('3. MRI — Useful when biliary communication suspected', bold=True)
add_para('4. ERCP / MRCP — Identifies biliary communication; use pre-operatively if fistula suspected', bold=True)
add_para('5. Chest X-ray — Elevated right hemidiaphragm; concentric calcifications; limited value alone', bold=True)

doc.add_paragraph()

# ═══════════════════════════════════════════
# SECTION 6 — MANAGEMENT
# ═══════════════════════════════════════════
add_heading('6. MANAGEMENT', level=1, color=(0x1F, 0x4E, 0x79))

add_para('Three Basic Principles of Management (Maingot\'s):', bold=True)
add_bullet('1. Eradication of the parasite within the cyst')
add_bullet('2. Protection against spillage of scoleces (prevent anaphylaxis + secondary seeding)')
add_bullet('3. Management of complications')

doc.add_paragraph()
add_heading('A. Medical (Antihelmintic) Therapy', level=2, color=(0x2E, 0x75, 0xB6))
add_table(
    ['Drug', 'Details'],
    [
        ['Albendazole (DRUG OF CHOICE)', '400 mg BD in 28-day cycles (14-day rest); min. 3 months pre-op; reduces recurrence; sole therapy success only ~30%'],
        ['Mebendazole', 'Poorly absorbed; inactivated by liver — second choice'],
        ['Praziquantel', 'Kills protoscoleces rapidly; used in combination with albendazole'],
    ]
)
doc.add_paragraph()
add_bullet('Indications for medical-only: Small (<4 cm), deep parenchymal, uncomplicated cysts; inoperable patients')

doc.add_paragraph()
add_heading('B. Percutaneous Treatment — PAIR', level=2, color=(0x2E, 0x75, 0xB6))
add_para('PAIR = Puncture, Aspiration, Injection, Re-aspiration', bold=True)
add_bullet('Done under USG guidance after albendazole pre-treatment')
add_bullet('Scolicidal agents: 15–20% hypertonic saline, 95% ethanol, 0.5% cetrimide, 5% povidone-iodine')
add_para('Steps:', bold=True)
for step in ['1. USG-guided puncture of cyst', '2. Aspiration of fluid (confirm scoleces = diagnosis)', '3. Injection of scolicidal agent (leave 15–30 min)', '4. Re-aspiration of all contents']:
    p = doc.add_paragraph(style='List Number')
    p.add_run(step).font.size = Pt(11)
add_para('CAUTION: NOT if biliary communication present (scolicidal agent causes sclerosing cholangitis)', bold=True)

doc.add_paragraph()
add_heading('C. Surgical Treatment', level=2, color=(0x2E, 0x75, 0xB6))
add_para('Pre-op: Albendazole 3 months; ERCP/MRCP to define biliary anatomy. Protect field with scolicidal-soaked packs.', bold=False)

add_table(
    ['Procedure', 'Details'],
    [
        ['Deroofing (Aspiration + Drainage)', 'Most common; aspirate contents, instil scolicidal agent, unroof cyst, remove endocyst. Cavity managed by omentoplasty / capitonnage / external drainage / Roux-en-Y (if biliary communication)'],
        ['Pericystectomy (Total/Partial)', 'Remove entire cyst including pericyst; preferred when feasible; can be laparoscopic'],
        ['Laparoscopic management', 'Laparoscopic deroofing/marsupialisation; aspirate first; biliary communication oversewn; omentum sutured to margins'],
        ['Formal Liver Resection', 'Multiple cysts near major supply; Gharbi IV/V; large/posterior/central cysts'],
        ['Liver Transplantation', 'E. multilocularis causing fulminant hepatic failure / Budd-Chiari syndrome (rare)'],
    ]
)
doc.add_paragraph()

add_para('Treatment Decision (Maingot\'s):', bold=True)
add_table(
    ['Percutaneous / Laparoscopic', 'Open / Resection'],
    [
        ['Gharbi Type I or II', 'Gharbi Type IV or V'],
        ['Anterior / peripheral cysts', 'Posterior / central cysts'],
        ['1–3 cysts, small size', '>3 cysts, large size'],
        ['No calcification', 'Heavy calcification'],
        ['No biliary communication', 'Biliary communication present'],
    ]
)
doc.add_paragraph()

# ═══════════════════════════════════════════
# SECTION 7 — COMPLICATIONS
# ═══════════════════════════════════════════
add_heading('7. COMPLICATIONS', level=1, color=(0x1F, 0x4E, 0x79))
add_para('One-third of patients develop complications (Maingot\'s).', bold=True)

add_table(
    ['Complication', 'Details'],
    [
        ['1. Cyst rupture (MOST COMMON)', 'Into peritoneal cavity (secondary peritoneal echinococcosis), biliary tree, bronchi, or pleura'],
        ['2. Biliary communication', 'Bile ducts incorporated into pericyst; presents as jaundice, cholangitis, or bilious contents on aspiration'],
        ['3. Secondary infection', 'Bacterial superinfection → pyogenic abscess'],
        ['4. Anaphylactic shock', 'Sudden rupture releases antigenic hydatid fluid — EMERGENCY'],
        ['5. Intrabiliary rupture', 'Obstructive jaundice + cholangitis; treat with ERCP + surgical biliary drainage'],
        ['6. Intrathoracic rupture', 'Hepato-bronchial fistula; patient coughs up white material (scoleces)'],
        ['7. CNS involvement', 'Even small cysts → severe symptoms due to confined space'],
        ['8. Bone involvement', 'Expansile lytic lesions, pathological fracture'],
        ['9. Calcification', 'Indicates dead/inactive cyst'],
    ]
)
doc.add_paragraph()
add_bullet('Daughter cyst seeding after spillage = secondary peritoneal echinococcosis (dreaded complication)')
add_bullet('MRCP shows biliary communication — get pre-op if suspected')

doc.add_paragraph()

# ═══════════════════════════════════════════
# SECTION 8 — RECENT ADVANCES
# ═══════════════════════════════════════════
add_heading('8. RECENT ADVANCES', level=1, color=(0x1F, 0x4E, 0x79))
recent = [
    'Laparoscopic pericystectomy/deroofing — now standard at experienced centres',
    'Single-incision laparoscopic surgery (SILS) for hepatic hydatid',
    'PAIR + combination albendazole + praziquantel — improving medical outcomes',
    'Radiofrequency ablation (RFA) — being explored for small, deep cysts',
    'Multidisciplinary management in tertiary units: hepatobiliary surgeon + physician + interventional radiologist',
    'WHO 2001 CE classification (CE stages 1–5) — guiding individualized therapy',
]
for r in recent:
    add_bullet(r)

doc.add_paragraph()

# ═══════════════════════════════════════════
# SCORING GUIDE
# ═══════════════════════════════════════════
add_heading('EXAMINER\'S SCORING PATTERN (30 Marks)', level=1, color=(0x1F, 0x4E, 0x79))
add_table(
    ['Section', 'Expected Marks'],
    [
        ['Surgical anatomy of liver + Couinaud diagram', '6'],
        ['Functions of liver (tabular/listed)', '4'],
        ['Life cycle of E. granulosus (with diagram)', '6'],
        ['Clinical presentation', '4'],
        ['Investigations (USG classification especially)', '4'],
        ['Management (PAIR + surgical options)', '5'],
        ['Complications', '1'],
        ['TOTAL', '30'],
    ]
)
doc.add_paragraph()

add_heading('Mark-Winning Habits', level=2, color=(0x2E, 0x75, 0xB6))
tips = [
    'Draw Couinaud\'s segmental anatomy diagram with segment numbers',
    'Draw the life cycle as a circular diagram with hosts labeled',
    'Use Gharbi AND WHO-CE classification for USG — examiners love seeing both',
    'Bold eponyms: PAIR, Gharbi classification, Cantlie\'s line, Hydatid sand',
    'State the 3 basic principles of management BEFORE listing surgical options',
    'Label all diagrams clearly — "Draw diagram wherever necessary" on every cover sheet',
]
for t in tips:
    add_bullet(t)

doc.add_paragraph()

# Sources
p_src = doc.add_paragraph()
run_src = p_src.add_run('Sources: Maingot\'s Abdominal Operations (p. 933–940) | Bailey and Love\'s Short Practice of Surgery, 28th Ed. (p. 95–97) | Sabiston Textbook of Surgery (p. 2183–2191)')
run_src.italic = True
run_src.font.size = Pt(9)
run_src.font.color.rgb = RGBColor(0x70, 0x70, 0x70)

# Save
out_path = '/tmp/workspace/ms-surgery-notes/Hydatid_Cyst_Liver_30marks.docx'
doc.save(out_path)
print(f'Saved: {out_path}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()

section = doc.sections[0]
section.top_margin = Cm(2)
section.bottom_margin = Cm(2)
section.left_margin = Cm(2.5)
section.right_margin = Cm(2.5)

normal_style = doc.styles['Normal']
normal_style.font.name = 'Arial'
normal_style.font.size = Pt(11)
for i in range(1, 4):
    h = doc.styles[f'Heading {i}']
    h.font.name = 'Arial'

def add_heading(text, level=1, color=(0x1F, 0x4E, 0x79)):
    p = doc.add_heading(text, level=level)
    for run in p.runs:
        run.font.color.rgb = RGBColor(*color)
    return p

def add_para(text, bold=False, italic=False, size=11, color=None):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = bold
    run.italic = italic
    run.font.size = Pt(size)
    if color:
        run.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def add_bullet(text, bold_prefix=None):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    if bold_prefix:
        run = p.add_run(bold_prefix)
        run.bold = True
        run.font.size = Pt(11)
        rest = p.add_run(text)
        rest.font.size = Pt(11)
    else:
        run = p.add_run(text)
        run.font.size = Pt(11)
    return p

def set_cell_bg(cell, hex_color):
    tc = cell._tc
    tcPr = tc.get_or_add_tcPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear')
    shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), hex_color)
    tcPr.append(shd)

def add_table(headers, rows):
    table = doc.add_table(rows=1 + len(rows), cols=len(headers))
    table.style = 'Table Grid'
    hdr_cells = table.rows[0].cells
    for i, h in enumerate(headers):
        hdr_cells[i].text = h
        set_cell_bg(hdr_cells[i], '1F4E79')
        for para in hdr_cells[i].paragraphs:
            for run in para.runs:
                run.bold = True
                run.font.size = Pt(10)
                run.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
    for r_idx, row_data in enumerate(rows):
        row_cells = table.rows[r_idx + 1].cells
        for c_idx, cell_text in enumerate(row_data):
            row_cells[c_idx].text = cell_text
            for para in row_cells[c_idx].paragraphs:
                for run in para.runs:
                    run.font.size = Pt(10)
        if r_idx % 2 == 0:
            for cell in row_cells:
                set_cell_bg(cell, 'D6E4F0')
    return table

# ── COVER ──────────────────────────────────────────────────────
p = doc.add_paragraph()
p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run('MS GENERAL SURGERY — EXAM NOTES')
run.bold = True; run.font.size = Pt(18); run.font.color.rgb = RGBColor(0x1F, 0x4E, 0x79)

p2 = doc.add_paragraph()
p2.alignment = WD_ALIGN_PARAGRAPH.CENTER
run2 = p2.add_run('Parotid Gland — Surgical Anatomy + Tumours (30-Mark Question)')
run2.bold = True; run2.font.size = Pt(14); run2.font.color.rgb = RGBColor(0x2E, 0x75, 0xB6)

p3 = doc.add_paragraph()
p3.alignment = WD_ALIGN_PARAGRAPH.CENTER
run3 = p3.add_run("Sources: Scott-Brown's Otorhinolaryngology | Cummings Otolaryngology | Robbins & Cotran Pathology")
run3.italic = True; run3.font.size = Pt(10); run3.font.color.rgb = RGBColor(0x70, 0x70, 0x70)

doc.add_paragraph()

p_q = doc.add_paragraph()
run_q = p_q.add_run('EXAM QUESTION: "Describe the surgical anatomy of parotid gland. Mention the classification of salivary gland tumours. Describe the pleomorphic adenoma of parotid in detail. / Write Anatomy of Facial nerve. Write in detail about Parotid Tumours."   [30 Marks]')
run_q.bold = True; run_q.font.size = Pt(11); run_q.font.color.rgb = RGBColor(0x7B, 0x22, 0x00)
doc.add_paragraph()

# ── SECTION 1: SURGICAL ANATOMY ────────────────────────────────
add_heading('1. SURGICAL ANATOMY OF PAROTID GLAND', level=1)
add_para('TIP: Draw the parotid gland showing its lobes, facial nerve branches, Stensen\'s duct and relations — earns 5-6 marks.', bold=True, color=(0x7B, 0x22, 0x00))

# Embed parotid anatomy image
img_url = 'https://cdn.orris.care/cdss_images/72ec9a7541da0d872a50b75b92b4e4c63655b29845870cc6e0ea729989b5b1a8.png'
img_path = '/tmp/workspace/ms-surgery-notes/parotid_anatomy.png'
try:
    r = requests.get(img_url, timeout=15)
    if r.status_code == 200:
        with open(img_path, 'wb') as f:
            f.write(r.content)
        doc.add_picture(img_path, width=Inches(5.5))
        doc.paragraphs[-1].alignment = WD_ALIGN_PARAGRAPH.CENTER
        cap = doc.add_paragraph("Figure: Surgical anatomy of parotid gland and facial nerve branches (Scott-Brown's Otorhinolaryngology)")
        cap.alignment = WD_ALIGN_PARAGRAPH.CENTER
        cap.runs[0].italic = True; cap.runs[0].font.size = Pt(9)
except Exception as e:
    add_para('[Parotid anatomy diagram — see Scott-Brown\'s Fig. 43.2]')

doc.add_paragraph()

add_heading('General Features', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Largest salivary gland; purely SEROUS secretion')
add_bullet('Wedge-shaped; weight ~25 g')
add_bullet('Located in the parotid region between the ear and angle of mandible')
add_bullet('Produces ~25% of daily saliva (600-1000 mL/day total)')
add_bullet('Accessory lobe: lies on masseter between parotid duct and zygomatic arch')

add_heading('Surfaces and Relations', level=2, color=(0x2E, 0x75, 0xB6))
add_table(
    ['Surface', 'Relations'],
    [
        ['Superficial (lateral)', 'Parotid fascia, skin, posterior platysma, superficial lymph nodes, great auricular nerve'],
        ['Anteromedial', 'Ascending ramus of mandible, medial pterygoid muscle, temporomandibular joint'],
        ['Posteromedial', 'Mastoid process, posterior belly of digastric, SCM; deeper: styloid process + muscles → separates from ICA and IJV'],
    ]
)
doc.add_paragraph()

add_heading('Lobes (Surgical Division)', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Facial nerve divides the gland into: Superficial lobe (~80%) and Deep lobe (~20%)')
add_bullet('Retromandibular vein lies deep to the facial nerve — useful radiological landmark on MRI')
add_bullet('90% of parotid tumours arise from the superficial lobe')
add_bullet('Deep lobe tumours expand into the parapharyngeal space')
add_bullet('Tumours at the stylomandibular ligament form a DUMBBELL MASS expanding both ways')

add_heading("Parotid Duct (Stensen's Duct)", level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Length: ~5 cm; internal calibre: ~0.6 mm')
add_bullet('Emerges from anterior border of parotid; crosses masseter')
add_bullet('Turns medially at anterior border of masseter, pierces buccinator')
add_bullet('Opens at PAROTID PAPILLA opposite the SECOND UPPER MOLAR TOOTH')
add_bullet('Surface marking: midpoint of line from intertragal notch to midpoint of philtrum')
add_bullet('KEY: Facial nerve branches are ALWAYS LATERAL to the parotid duct')

add_heading('Capsule', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Formed by split of deep cervical fascia = parotid (parotidomas-seteric) fascia')
add_bullet('Overlying SMAS is adherent to parotidomas-seteric fascia in the pretragal area')
add_bullet('Stylomandibular ligament = thickened deep fascia between styloid process and angle of mandible')
add_bullet('Thin anteriorly — inflammatory spread can track into parapharyngeal space through thin apex')

add_heading('Lymphatic Drainage', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Superficial nodes (on/deep to fascia): drain skin of forehead, temple, periauricular skin')
add_bullet('Deep nodes (within gland): drain nasal cavity, palate, middle ear, EAM')
add_bullet('Both drain to upper deep cervical nodes')

doc.add_paragraph()

# ── SECTION 2: FACIAL NERVE ────────────────────────────────────
add_heading('2. FACIAL NERVE — THE KEY SURGICAL STRUCTURE', level=1)
add_para('The facial nerve is the most surgically important structure in all parotid operations. Always identify and preserve it.', bold=True, color=(0xC0, 0x00, 0x00))

add_heading('Course of Facial Nerve', level=2, color=(0x2E, 0x75, 0xB6))
steps = [
    'Exits skull through STYLOMASTOID FORAMEN (deep to junction of cartilaginous and bony EAM)',
    'Main trunk lies ~1 cm above the posterior belly of digastric',
    'Passes downward over styloid process; gives off: posterior auricular branch, branch to posterior digastric and stylohyoid',
    'Enters parotid substance from posteromedial surface between mastoid and styloid processes',
    'Within gland: divides into upper (zygomaticotemporal) and lower (cervicofacial) divisions',
    'Further subdivides into 5 terminal branches = PES ANSERINUS',
]
for i, s in enumerate(steps, 1):
    p = doc.add_paragraph(style='List Number')
    p.add_run(s).font.size = Pt(11)

doc.add_paragraph()
add_table(
    ['Branch', 'Muscles Supplied'],
    [
        ['Temporal (Frontal)', 'Frontalis, orbicularis oculi (upper), corrugator'],
        ['Zygomatic', 'Orbicularis oculi (lower), zygomaticus'],
        ['Buccal', 'Buccinator, orbicularis oris'],
        ['Marginal Mandibular', 'Depressors of lip, mentalis — MOST VULNERABLE (least cross-innervation)'],
        ['Cervical', 'Platysma'],
    ]
)
doc.add_paragraph()

add_heading('Surgical Landmarks for Finding Facial Nerve Trunk', level=2, color=(0x2E, 0x75, 0xB6))
add_para('MEMORISE ALL 4 — examiner may ask these directly:', bold=True)
add_bullet('1. TRAGAL POINTER: Nerve lies 1 cm deep and inferior to tip of tragal cartilage')
add_bullet('2. POSTERIOR BELLY OF DIGASTRIC: Nerve is just above its superior border')
add_bullet('3. TYMPANOMASTOID SUTURE: Nerve exits 6-8 mm deep to inferior end')
add_bullet('4. RETROMANDIBULAR VEIN: Facial nerve lies superficial to it (useful on MRI)')

add_heading('Secretomotor (Parasympathetic) Pathway — Exam Favourite!', level=2, color=(0x2E, 0x75, 0xB6))
add_para('Inferior salivatory nucleus (medulla) → Glossopharyngeal nerve (CN IX) → Tympanic branch → Tympanic plexus → Lesser petrosal nerve → OTIC GANGLION → Auriculotemporal nerve → Parotid gland', bold=False)
add_bullet('Sympathetic (vasoconstrictor): plexus on external carotid artery → from superior cervical ganglion')

add_heading('Blood Supply', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Arterial: External carotid artery divides WITHIN the gland into maxillary and superficial temporal arteries')
add_bullet('Venous: Maxillary + superficial temporal veins → retromandibular vein within the gland')

doc.add_paragraph()

# ── SECTION 3: CLASSIFICATION ──────────────────────────────────
add_heading('3. CLASSIFICATION OF SALIVARY GLAND TUMOURS', level=1)
add_para('KEY RULE: The smaller the salivary gland, the HIGHER the chance of malignancy.', bold=True, color=(0xC0, 0x00, 0x00))

add_table(
    ['Gland', '% of all salivary tumours', '% Malignant'],
    [
        ['Parotid', '65-80%', '20-25%'],
        ['Submandibular', '10%', '40%'],
        ['Sublingual', '<5%', '70-90%'],
        ['Minor salivary glands', 'Remainder', '50%'],
    ]
)
doc.add_paragraph()

add_para('WHO Histological Classification (Robbins & Cotran):', bold=True)
add_table(
    ['BENIGN', 'MALIGNANT'],
    [
        ['Pleomorphic adenoma (Mixed tumour) — MOST COMMON', 'Mucoepidermoid carcinoma — Most common malignant'],
        ["Warthin's tumour (Cystadenolymphoma)", 'Acinic cell carcinoma'],
        ['Oncocytoma', 'Adenoid cystic carcinoma'],
        ['Canalicular adenoma', 'Salivary duct carcinoma'],
        ['Basal cell adenoma', 'Carcinoma ex pleomorphic adenoma'],
        ['Myoepithelioma', 'Adenocarcinoma, NOS'],
    ]
)
doc.add_paragraph()

# ── SECTION 4: PLEOMORPHIC ADENOMA ────────────────────────────
add_heading('4. PLEOMORPHIC ADENOMA (MIXED TUMOUR) — IN DETAIL', level=1)

add_heading('Incidence & Epidemiology', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Most common salivary gland neoplasm overall')
add_bullet('Represents ~60% of parotid tumours; 80% arise in superficial lobe')
add_bullet('Peak age: 30-60 years; slight female preponderance')
add_bullet('Radiation exposure increases risk')

add_heading('Pathogenesis', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Mixed tumour: ductal (epithelial) + myoepithelial + mesenchymal cells')
add_bullet('PLAG1 transcription factor overexpression (chromosomal rearrangement)')
add_bullet('HMGA2 gene mutations in PLAG1-normal cases')

add_heading('Macroscopy', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Rounded, well-demarcated, firm mass; rarely exceeds 6 cm')
add_bullet('PSEUDO-CAPSULE (NOT true capsule) — contains tongue-like projections through the capsule')
add_bullet('This is why SIMPLE ENUCLEATION IS CONDEMNED — causes high recurrence (20-45%)')

add_heading('Microscopy', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Ductal elements: tubules, sheets of epithelial cells')
add_bullet('Myoepithelial cells: spindle cells, plasmacytoid cells')
add_bullet('Mesenchymal-like stroma: myxoid, chondroid, hyaline areas')
add_para('"Mixed" histology explains the name and the pseudo-capsular projections', italic=True)

add_heading('Clinical Features', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Slow-growing, painless, firm mass anterior to ear or at angle of mandible')
add_bullet('Present for months to years; mobile, non-tender')
add_bullet('NO facial nerve palsy (palsy = malignancy)')
add_bullet('No skin fixation; no cervical lymphadenopathy')

add_heading('Investigations', level=2, color=(0x2E, 0x75, 0xB6))
add_table(
    ['Investigation', 'Role'],
    [
        ['FNAC (Fine Needle Aspiration)', 'First investigation; accuracy 90-95% with on-site cytopathologist'],
        ['Ultrasound', 'Well-defined hypoechoic smooth lesion; guides FNAC; confirms superficial lobe'],
        ['MRI', 'Deep lobe tumours, parapharyngeal extension, perineural spread; uses retromandibular vein to plot nerve trajectory'],
        ['CT Scan', 'Deep lobe and bone involvement'],
    ]
)
doc.add_paragraph()

add_heading('Management — SURGICAL', level=2, color=(0x2E, 0x75, 0xB6))
add_para('Treatment = Superficial Parotidectomy with facial nerve preservation. ENUCLEATION IS CONDEMNED.', bold=True, color=(0xC0, 0x00, 0x00))

add_para('Steps of Superficial Parotidectomy:', bold=True)
surgery_steps = [
    'Modified Blair incision (pre-auricular + cervical extension)',
    'Raise skin flap in sub-SMAS plane',
    'Identify facial nerve trunk using landmarks (tragal pointer, digastric, tympanomastoid suture)',
    'Trace all branches of facial nerve distally (anterograde dissection)',
    'Remove superficial lobe with tumour, keeping nerve intact',
    'If deep lobe involvement: total parotidectomy preserving facial nerve',
    'Closure with drain; check facial nerve function immediately post-op',
]
for i, s in enumerate(surgery_steps, 1):
    p = doc.add_paragraph(style='List Number')
    p.add_run(s).font.size = Pt(11)

doc.add_paragraph()
add_bullet('Extracapsular Dissection (ECD): conservative alternative for small, superficial, mobile tumours; dissect just outside capsule with 5 mm normal tissue cuff')

add_heading('Recurrence', level=2, color=(0x2E, 0x75, 0xB6))
add_table(
    ['Procedure', 'Recurrence Rate'],
    [
        ['Formal parotidectomy', '1-5%'],
        ['Enucleation (CONDEMNED)', '20-45%'],
        ['Recurrent disease', 'Multinodular; complex re-excision required'],
    ]
)
doc.add_paragraph()

add_heading('Malignant Transformation → Carcinoma Ex Pleomorphic Adenoma', level=2, color=(0x2E, 0x75, 0xB6))
add_bullet('Risk increases with time: ~2% at 5 years → ~10% at 15 years → ~25% at 25+ years')
add_bullet('Warning signs: sudden rapid growth, pain, facial nerve palsy, skin fixation, nodal metastasis')
add_bullet('Treatment: total parotidectomy + neck dissection + radiotherapy; poor prognosis')

doc.add_paragraph()

# ── SECTION 5: WARTHIN'S ──────────────────────────────────────
add_heading("5. WARTHIN'S TUMOUR (Cystadenolymphoma)", level=1)
add_bullet('2nd most common benign parotid tumour')
add_bullet('Almost exclusively in parotid gland (no lymphoid tissue in other glands)')
add_bullet('Strongly associated with SMOKING (8x increased risk)')
add_bullet('BILATERAL IN 10% — unique among parotid tumours')
add_bullet('Age: 5th-6th decade; M > F')
add_bullet('Histology: double layer of oncocytic (Hurthle) cells + lymphoid stroma with germinal centres')
add_bullet('Management: surgical excision; conservative approach in elderly/frail with confirmed core biopsy diagnosis')

doc.add_paragraph()

# ── SECTION 6: MALIGNANT TUMOURS ─────────────────────────────
add_heading('6. MALIGNANT PAROTID TUMOURS', level=1)

add_para('FEATURES SUGGESTING MALIGNANCY:', bold=True, color=(0xC0, 0x00, 0x00))
add_table(
    ['Feature', 'Significance'],
    [
        ['FACIAL NERVE PALSY', 'Pathognomonic of malignant parotid tumour'],
        ['Pain', 'Perineural invasion'],
        ['Rapid growth', 'High-grade tumour'],
        ['Skin fixation / ulceration', 'Advanced invasion'],
        ['Hard, irregular, fixed mass', 'Invasive tumour'],
        ['Cervical lymphadenopathy', 'Nodal metastases'],
    ]
)
doc.add_paragraph()
add_para('"Facial palsy in a parotid mass = malignant until proven otherwise"', bold=True, color=(0xC0, 0x00, 0x00))
doc.add_paragraph()

add_heading('Types of Malignant Tumours', level=2, color=(0x2E, 0x75, 0xB6))
add_table(
    ['Tumour', 'Key Features', 'Treatment'],
    [
        ['Mucoepidermoid carcinoma (MOST COMMON)', 'Low-grade and high-grade forms; mixture of mucous + epidermoid + intermediate cells', 'Total parotidectomy ± neck dissection; RT for high-grade'],
        ['Adenoid cystic carcinoma', 'PERINEURAL INVASION (pain, palsy even early); cribriform "Swiss cheese" histology; late recurrences even after 20 years; more common in minor salivary glands', 'Wide excision + post-op radiotherapy'],
        ['Acinic cell carcinoma', 'Low-grade malignancy; good prognosis; resembles acinar cells', 'Superficial/total parotidectomy; rarely needs neck dissection'],
        ['Carcinoma ex pleomorphic adenoma', 'Malignant transformation in pre-existing PA; sudden rapid growth in long-standing mass', 'Total parotidectomy + neck dissection + RT; poor prognosis'],
    ]
)
doc.add_paragraph()

add_heading('Management of Malignant Parotid Tumours', level=2, color=(0x2E, 0x75, 0xB6))
add_para('Principles:', bold=True)
principles = [
    'Total parotidectomy with facial nerve preservation if possible',
    'Sacrifice facial nerve ONLY if directly invaded (confirm with frozen section); reconstruct with sural nerve graft or hypoglossal-facial anastomosis',
    'Selective neck dissection (levels I-III) for clinically N0 if high-grade tumour',
    'Therapeutic neck dissection for N+ disease',
    'Post-operative radiotherapy for: high-grade tumours, perineural invasion, bone involvement, close/positive margins, N+ disease',
]
for i, s in enumerate(principles, 1):
    p = doc.add_paragraph(style='List Number')
    p.add_run(s).font.size = Pt(11)

doc.add_paragraph()

# ── SECTION 7: COMPLICATIONS ──────────────────────────────────
add_heading('7. COMPLICATIONS OF PAROTID SURGERY', level=1)
add_table(
    ['Complication', 'Details'],
    [
        ['Facial nerve palsy (most feared)', 'Transient (neuropraxia) > permanent; marginal mandibular most vulnerable due to least cross-innervation'],
        ["FREY'S SYNDROME (Auriculotemporal syndrome)", 'Gustatory sweating — sweating/flushing over cheek while eating; aberrant reinnervation of sweat glands by parasympathetic fibres from auriculotemporal nerve; treat with botulinum toxin injection'],
        ['Great auricular nerve damage', 'Numbness/dysaesthesia of pinna; try to preserve posterior branch'],
        ['Salivary fistula', 'Salivary leak from skin; treat conservatively (pressure dressing, anticholinergics)'],
        ['Haematoma', 'Early post-op; can compress airway — emergency re-exploration'],
        ['Recurrence (pleomorphic adenoma)', 'If enucleation was done; multinodular recurrence — complex re-surgery'],
    ]
)
doc.add_paragraph()
add_para("Frey's syndrome mechanism: parasympathetic (secretomotor) fibres from the auriculotemporal nerve aberrantly reinnervate sympathetic receptors on sweat glands of facial skin during healing → eating triggers sweating instead of salivation.", italic=True)

doc.add_paragraph()

# ── SCORING GUIDE ─────────────────────────────────────────────
add_heading("EXAMINER'S SCORING PATTERN (30 Marks)", level=1)
add_table(
    ['Section', 'Expected Marks'],
    [
        ["Surgical anatomy of parotid (lobes, surfaces, duct, capsule)", '6'],
        ['Facial nerve anatomy, branches, surgical landmarks + diagram', '7'],
        ['Nerve supply of parotid (secretomotor pathway)', '2'],
        ['Classification of salivary gland tumours (table)', '3'],
        ['Pleomorphic adenoma (pathology, features, surgery)', '8'],
        ['Malignant tumours (features, types, management)', '3'],
        ['Complications', '1'],
        ['TOTAL', '30'],
    ]
)
doc.add_paragraph()

add_heading('Mark-Winning Habits', level=2, color=(0x2E, 0x75, 0xB6))
tips = [
    "Draw the FACIAL NERVE BRANCHING diagram inside the parotid — Pes Anserinus pattern (5 branches)",
    "State ALL 3-4 surgical landmarks for finding the facial nerve trunk (tragal pointer, digastric, tympanomastoid suture)",
    "Emphasise the PSEUDO-CAPSULE of pleomorphic adenoma as the reason enucleation is condemned",
    '"Facial palsy = malignancy" — write this explicitly',
    "Know Frey\'s syndrome mechanism and treatment (botulinum toxin) — often asked as a short note",
    "Adenoid cystic carcinoma — perineural invasion + cribriform histology + late recurrences = three key points",
    "Remember WARTHINS = Bilateral + Smoking association (unique features worth extra marks)",
]
for t in tips:
    add_bullet(t)

doc.add_paragraph()
p_src = doc.add_paragraph()
run_src = p_src.add_run("Sources: Scott-Brown's Otorhinolaryngology Head & Neck Surgery (p. 721-724, 744) | Cummings Otolaryngology Head & Neck Surgery | Robbins & Cotran Pathologic Basis of Disease (p. 695-698)")
run_src.italic = True; run_src.font.size = Pt(9); run_src.font.color.rgb = RGBColor(0x70, 0x70, 0x70)

out_path = '/tmp/workspace/ms-surgery-notes/Parotid_Gland_Tumours_30marks.docx'
doc.save(out_path)
print(f'Saved: {out_path}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement

doc = Document()
section = doc.sections[0]
section.top_margin = Cm(2); section.bottom_margin = Cm(2)
section.left_margin = Cm(2.5); section.right_margin = Cm(2.5)

normal_style = doc.styles['Normal']
normal_style.font.name = 'Arial'; normal_style.font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def add_heading(text, level=1, color=(0x1F, 0x4E, 0x79)):
    p = doc.add_heading(text, level=level)
    for run in p.runs:
        run.font.color.rgb = RGBColor(*color)
    return p

def add_para(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = bold; run.italic = italic; run.font.size = Pt(size)
    if color: run.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def add_bullet(text):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    p.add_run(text).font.size = Pt(11)
    return p

def set_cell_bg(cell, hex_color):
    tc = cell._tc; tcPr = tc.get_or_add_tcPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear'); shd.set(qn('w:color'), 'auto'); shd.set(qn('w:fill'), hex_color)
    tcPr.append(shd)

def add_table(headers, rows):
    table = doc.add_table(rows=1+len(rows), cols=len(headers))
    table.style = 'Table Grid'
    hdr = table.rows[0].cells
    for i, h in enumerate(headers):
        hdr[i].text = h; set_cell_bg(hdr[i], '1F4E79')
        for para in hdr[i].paragraphs:
            for run in para.runs:
                run.bold = True; run.font.size = Pt(10); run.font.color.rgb = RGBColor(0xFF,0xFF,0xFF)
    for ri, row_data in enumerate(rows):
        cells = table.rows[ri+1].cells
        for ci, txt in enumerate(row_data):
            cells[ci].text = txt
            for para in cells[ci].paragraphs:
                for run in para.runs: run.font.size = Pt(10)
        if ri % 2 == 0:
            for cell in cells: set_cell_bg(cell, 'D6E4F0')
    return table

# COVER
p = doc.add_paragraph(); p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run('MS GENERAL SURGERY — EXAM NOTES')
run.bold = True; run.font.size = Pt(18); run.font.color.rgb = RGBColor(0x1F,0x4E,0x79)

p2 = doc.add_paragraph(); p2.alignment = WD_ALIGN_PARAGRAPH.CENTER
run2 = p2.add_run('Upper Gastrointestinal Bleeding (UGIB) — 30-Mark Question')
run2.bold = True; run2.font.size = Pt(14); run2.font.color.rgb = RGBColor(0x2E,0x75,0xB6)

p3 = doc.add_paragraph(); p3.alignment = WD_ALIGN_PARAGRAPH.CENTER
run3 = p3.add_run("Sources: Sleisenger & Fordtran's GI & Liver Disease | Fischer's Mastery of Surgery 8th Ed. | Bailey & Love 28th Ed.")
run3.italic = True; run3.font.size = Pt(10); run3.font.color.rgb = RGBColor(0x70,0x70,0x70)
doc.add_paragraph()

pq = doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Upper gastrointestinal bleeding — etiopathogenesis, D/D, clinical presentation and management."   [30 Marks]').bold = True
pq.runs[0].font.size = Pt(11); pq.runs[0].font.color.rgb = RGBColor(0x7B,0x22,0x00)
doc.add_paragraph()

# ── DEFINITION
add_heading('DEFINITION & EPIDEMIOLOGY', level=1)
add_para('UGIB = haemorrhage PROXIMAL to the LIGAMENT OF TREITZ (oesophagus, stomach, duodenum).', bold=True)
add_bullet('Results in >300,000 hospitalizations/year')
add_bullet('Overall mortality: 5-10% (unchanged since 1970s — more elderly patients with comorbidities)')
add_bullet('Self-limiting in 80% of patients without specific therapy')
add_bullet('In 20% who continue bleeding or rebleed: mortality 30-40%')
add_bullet('Variceal bleeds: 20% mortality per subsequent bleeding event')
doc.add_paragraph()

# ── ETIOPATHOGENESIS
add_heading('1. ETIOPATHOGENESIS / CAUSES', level=1)
add_heading('A. Non-Variceal Causes (75-80% of UGIB)', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Cause', 'Frequency', 'Pathogenesis'],
    [
        ['Peptic Ulcer Disease (MOST COMMON)', '35-50%', 'H. pylori + NSAIDs erode mucosa → ulcer erodes vessel (posterior duodenal ulcer → gastroduodenal artery = most dangerous)'],
        ['Erosive gastritis / duodenitis', '~5%', 'NSAIDs inhibit COX-1 → ↓ prostaglandins → ↓ mucosal protection'],
        ['Mallory-Weiss tear', '~4%', 'Forceful vomiting → sudden ↑ intragastric pressure → mucosal tear at gastro-oesophageal junction'],
        ['Dieulafoy lesion', '~3%', 'Aberrant large-calibre submucosal artery erodes through mucosa; bleeds massively without ulceration'],
        ['Oesophagitis (GORD)', '~4%', 'Gastric acid reflux → mucosal erosion in distal oesophagus'],
        ['Neoplasm (Ca stomach / oesophagus)', '~3%', 'Tumour neovascularisation → vessel erosion'],
        ['Angiodysplasia', '~4%', 'Dilated mucosal vessels; mainly elderly; arteriovenous malformations'],
        ['Haemobilia', 'Rare', "Bleeding into biliary tree; Quincke's Triad: RUQ pain + jaundice + haematemesis"],
        ['Aorto-enteric fistula', 'Rare', 'Post-aortic surgery complication; herald bleed followed by massive haemorrhage'],
    ]
)
doc.add_paragraph()

add_heading('B. Variceal Causes (20-25% of UGIB)', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Cause', 'Notes'],
    [
        ['Oesophageal varices (MOST COMMON variceal)', 'Portal hypertension (cirrhosis) → portosystemic collaterals → varices at GEJ; portal pressure >12 mmHg triggers rupture'],
        ['Gastric varices', 'Less common but bleed more severely'],
        ['Portal hypertensive gastropathy', 'Congested gastric mucosa; diffuse mucosal bleeding'],
    ]
)
doc.add_paragraph()
add_para('KEY FACTS: 30% of cirrhotic patients have variceal bleeding; 60% rebleed within 12 months; 20% mortality per event.', bold=True, color=(0xC0,0x00,0x00))

add_heading('C. Pathological Mechanisms', level=2, color=(0x2E,0x75,0xB6))
mech = [
    'Acid-peptic disease: H. pylori (90% DU, 70% GU) + NSAIDs disrupt mucosal barrier → acid autodigestion → vessel erosion',
    'Portal hypertension: Cirrhosis → portal HTN → submucosal venous collaterals → varices → rupture when portal pressure >12 mmHg',
    'Vascular anomalies: Dieulafoy, angiodysplasia — thin mucosa over abnormal calibre vessels',
    "Mechanical disruption: Mallory-Weiss tear — retching + vomiting raises intragastric pressure abruptly",
    'Neoplastic erosion: Tumour neovascularisation bleeds readily',
]
for m in mech: add_bullet(m)
doc.add_paragraph()

# ── CLINICAL PRESENTATION
add_heading('2. CLINICAL PRESENTATION', level=1)
add_heading('Symptoms', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Symptom', 'Description', 'Significance'],
    [
        ['Haematemesis', 'Vomiting fresh red blood or coffee-ground material', 'Blood in stomach; brown = acid-altered (digested)'],
        ['Melaena', 'Loose, black, tarry, offensive-smelling stools', 'Digested blood; usually >100 mL blood; needs ≥8 hours transit; proximal to caecum'],
        ['Haematochezia', 'Bright red blood per rectum', 'Usually LGIB but can occur in brisk UGIB (>1 L blood)'],
        ['Syncope / dizziness', 'Postural hypotension, light-headedness', 'Haemodynamic compromise; >20% volume loss'],
        ['Epigastric pain before bleed', 'Chronic or acute onset', 'Peptic ulcer disease'],
        ['Dysphagia', 'Difficulty swallowing preceding bleed', 'Oesophageal cause (varices, carcinoma)'],
    ]
)
doc.add_paragraph()

add_heading('Haemodynamic Status', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Sign', 'Blood Volume Loss', 'Significance'],
    [
        ['Pulse >100 bpm', '15-30%', 'Class II shock'],
        ['Systolic BP <100 mmHg', '>30%', 'Class III shock — emergency'],
        ['Postural hypotension >20 mmHg', '~20%', 'Significant volume loss'],
        ['Cold extremities, altered sensorium', '>40%', 'Class IV shock — life-threatening'],
    ]
)
doc.add_paragraph()

add_heading('Signs on Examination', level=2, color=(0x2E,0x75,0xB6))
add_bullet('Pallor, tachycardia, hypotension')
add_bullet('Stigmata of chronic liver disease (variceal): spider naevi, palmar erythema, jaundice, ascites, caput medusae, splenomegaly')
add_bullet('Epigastric tenderness → PUD')
add_bullet('Acanthosis nigricans → gastric malignancy; Virchow\'s node → metastatic Ca stomach')
doc.add_paragraph()

# ── D/D
add_heading('3. DIFFERENTIAL DIAGNOSIS', level=1)
add_para('Write as two columns — Non-variceal vs Variceal:', bold=True)
add_table(
    ['Non-Variceal Causes', 'Variceal Causes'],
    [
        ['Peptic ulcer (gastric / duodenal)', 'Oesophageal varices'],
        ['Mallory-Weiss tear', 'Gastric varices'],
        ['Erosive gastritis / duodenitis', 'Portal hypertensive gastropathy'],
        ['Dieulafoy lesion', ''],
        ['Oesophagitis (GORD)', ''],
        ['Carcinoma of stomach / oesophagus', ''],
        ['Angiodysplasia', ''],
        ["Haemobilia (Quincke's Triad)", ''],
        ['Aorto-enteric fistula', ''],
        ['Epistaxis / haemoptysis (swallowed blood)', ''],
    ]
)
doc.add_paragraph()

# ── INVESTIGATIONS
add_heading('4. INVESTIGATIONS', level=1)

add_heading('Immediate (Emergency)', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Test', 'Significance'],
    [
        ['Full Blood Count (FBC)', 'Hb may be normal initially; falls over 6-24 hrs with haemodilution'],
        ['Blood grouping + Cross-matching', 'Order 4-6 units of packed red cells urgently'],
        ['Coagulation (PT/INR, aPTT)', 'Essential in cirrhosis; guides FFP/Vit K use'],
        ['LFTs + Serum albumin', 'Liver disease; hypoalbuminaemia = high risk'],
        ['BUN / Creatinine', 'Raised BUN with normal creatinine = UGIB (blood absorption and digestion)'],
        ['ECG', 'Baseline; detect ischaemia from hypoperfusion'],
    ]
)
doc.add_paragraph()

add_heading('Risk Stratification Scores', level=2, color=(0x2E,0x75,0xB6))
add_para('BLATCHFORD SCORE (Pre-endoscopy) — Variables: BUN, Hb, SBP, HR, syncope, melaena, liver disease, heart failure. Score 0 = safe early discharge.', bold=False)
doc.add_paragraph()
add_para('ROCKALL SCORE (Post-endoscopy — MOST IMPORTANT):', bold=True)
add_table(
    ['Variable', 'Score 0', 'Score 1', 'Score 2', 'Score 3'],
    [
        ['Age', '<60', '60-79', '≥80', '-'],
        ['Shock', 'No shock', 'Pulse>100, SBP≥100', 'SBP<100', '-'],
        ['Comorbidity', 'None', '-', 'Cardiac failure, IHD', 'Renal/hepatic failure, disseminated malignancy'],
        ['Endoscopic diagnosis', 'Mallory-Weiss / no lesion', 'All other diagnoses', '-', 'UGI malignancy'],
        ['Stigmata of haemorrhage', 'None / dark spot', '-', 'Blood in UGI, adherent clot, visible vessel, spurting', '-'],
    ]
)
doc.add_paragraph()
add_bullet('Score 0-2 = LOW RISK (<5% rebleed, <0.2% mortality) → early discharge')
add_bullet('Score ≥8 = HIGH RISK (>40% rebleed, >40% mortality) → HDU/ICU')
doc.add_paragraph()
add_para('AIMS65 Score (Pre-endoscopy mortality): Albumin<3, INR>1.5, Mental status altered, SBP<90, age>65. Score ≥2 = higher mortality.', bold=False)
doc.add_paragraph()

add_heading('Endoscopy (OGD) — THE KEY INVESTIGATION', level=2, color=(0x2E,0x75,0xB6))
add_para('Within 24 hours (12 hours if haemodynamically unstable); identifies source in 95%', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()
add_para('FORREST CLASSIFICATION (Peptic Ulcer findings on OGD):', bold=True)
add_table(
    ['Class', 'Finding', 'Rebleed Risk', 'Treatment'],
    [
        ['Ia', 'Active arterial SPURTING', '90%', 'Endoscopic haemostasis + IV PPI infusion'],
        ['Ib', 'Active OOZING', '10-27%', 'Endoscopic haemostasis + IV PPI infusion'],
        ['IIa', 'Non-bleeding VISIBLE VESSEL (NBVV)', '50%', 'Endoscopic haemostasis + IV PPI infusion'],
        ['IIb', 'ADHERENT CLOT over ulcer', '22-33%', 'Remove clot, treat underlying vessel'],
        ['IIc', 'Flat pigmented SPOT', '7-10%', 'PPI alone (intermediate risk)'],
        ['III', 'CLEAN BASE ulcer', '<5%', 'Oral PPI; early discharge safe'],
    ]
)
doc.add_paragraph()
add_para('HIGH RISK (treat endoscopically): Forrest Ia, Ib, IIa, IIb', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

add_heading('Additional Imaging', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Investigation', 'Indication'],
    [
        ['CT Angiography / DSA (Selective mesenteric angiography)', 'Active bleeding not controlled by endoscopy; detects >0.5 mL/min'],
        ['Radionuclide scan (99mTc-RBC scan)', 'Slow/intermittent bleeding; detects 0.1 mL/min'],
        ['Capsule endoscopy', 'Obscure GI bleeding; small bowel source'],
    ]
)
doc.add_paragraph()

# ── MANAGEMENT
add_heading('5. MANAGEMENT', level=1)

add_heading('STEP 1 — IMMEDIATE RESUSCITATION (ABCDE)', level=2, color=(0x2E,0x75,0xB6))
add_para('"Resuscitate FIRST, investigate SECOND"', bold=True, color=(0xC0,0x00,0x00))
resus = [
    'AIRWAY: Protect — consider ETT before endoscopy in massive haematemesis (risk of aspiration, especially in varices + encephalopathy)',
    'BREATHING: Oxygen by face mask',
    'CIRCULATION: 2 large-bore IV cannulae (14-16G); IV crystalloid (NS/Hartmann\'s); Blood transfusion — target Hb >8 g/dL; RESTRICTIVE transfusion strategy (target 7-9 g/dL) reduces mortality; AVOID over-transfusion in varices (raises portal pressure)',
    'CORRECT COAGULOPATHY: FFP if INR >1.5; Vitamin K 10 mg IV; Platelets if <50 × 10⁹/L',
    'MONITORING: Urinary catheter (target UO >0.5 mL/kg/hr); CVP if needed; pulse oximetry',
]
for i, s in enumerate(resus, 1):
    p = doc.add_paragraph(style='List Number')
    p.add_run(s).font.size = Pt(11)
doc.add_paragraph()

add_heading('STEP 2 — PHARMACOLOGICAL THERAPY', level=2, color=(0x2E,0x75,0xB6))
add_para('For NON-VARICEAL UGIB:', bold=True)
add_table(
    ['Drug', 'Dose / Details', 'Rationale'],
    [
        ['IV PPI (STANDARD OF CARE)', 'Omeprazole/Pantoprazole 80 mg bolus + 8 mg/hr infusion × 72 hrs', 'Raises gastric pH >6 → stabilises platelet plug; reduces rebleed from Forrest Ia/IIa by 50%'],
        ['Erythromycin (prokinetic)', '250 mg IV 30-90 min before endoscopy', 'Clears blood from stomach for better endoscopic visualisation'],
        ['H. pylori eradication', 'Triple therapy (PPI + amoxicillin + clarithromycin) after acute bleeding settles', 'Prevents recurrence of PUD-related bleeding'],
        ['Stop NSAIDs / anticoagulants', 'Immediate', 'Remove causative agent'],
    ]
)
doc.add_paragraph()
add_para('For VARICEAL UGIB:', bold=True)
add_table(
    ['Drug', 'Details'],
    [
        ['TERLIPRESSIN (Drug of Choice)', '2 mg IV 4-hourly × 48-72 hrs; vasopressin analogue; reduces splanchnic blood flow; ONLY vasoconstrictor with proven mortality benefit'],
        ['Somatostatin / Octreotide', '50 mcg bolus then 50 mcg/hr infusion; splanchnic vasoconstrictor'],
        ['Prophylactic Antibiotics', 'Ceftriaxone 1 g/day IV × 7 days; reduces bacterial translocation, SBP, and mortality in cirrhosis'],
        ['Vitamin K + FFP', 'Correct coagulopathy; Vit K 10 mg IV; FFP for INR >1.5'],
    ]
)
doc.add_paragraph()

add_heading('STEP 3 — ENDOSCOPIC MANAGEMENT (within 24 hrs)', level=2, color=(0x2E,0x75,0xB6))
add_para('For NON-VARICEAL (Peptic Ulcer):', bold=True)
add_table(
    ['Method', 'Technique'],
    [
        ['Epinephrine injection (most widely used)', '1:10,000 solution; injected circumferentially; temporary haemostasis only — ALWAYS combine with mechanical/thermal'],
        ['Haemoclips', 'Mechanical compression of bleeding vessel; best for visible vessel; durable haemostasis'],
        ['Thermal coagulation (MPEC / APC)', 'Heat coagulates vessel; multipolar electrocoagulation (MPEC) preferred'],
        ['COMBINATION THERAPY (Standard)', 'Epinephrine injection + haemoclip/thermal = gold standard; reduces rebleed vs injection alone'],
        ['Haemospray', 'Topical powder concentrates clotting factors; bridging measure only'],
        ['Over-the-scope clip (OTSC)', 'For recurrent/refractory bleeding; larger jaw → more effective vessel obliteration'],
    ]
)
doc.add_paragraph()
add_para('For VARICEAL:', bold=True)
add_table(
    ['Method', 'Details'],
    [
        ['Endoscopic Variceal Ligation / Banding (EVL) — FIRST CHOICE', 'Elastic bands at varix base → strangulate → thrombosis + necrosis; superior to sclerotherapy; 6-8 bands per session'],
        ['Sclerotherapy', 'Injection of sclerosant (ethanolamine oleate) into/around varix; when banding not feasible'],
    ]
)
doc.add_paragraph()

add_heading('STEP 4 — WHEN ENDOSCOPY FAILS: Salvage Options', level=2, color=(0x2E,0x75,0xB6))

add_para('Balloon Tamponade (Bridge only — NOT definitive):', bold=True)
add_bullet('Sengstaken-Blakemore (SB) tube: gastric + oesophageal balloons; gastric balloon 300 mL air → retract to fundus; oesophageal balloon to 60 mmHg')
add_bullet('Minnesota tube: SB tube + oesophageal aspiration port')
add_bullet('Complications: oesophageal rupture, aspiration (significant risk)')
add_bullet('Now largely replaced by Self-expanding metal stents (SEMS/Danis stent)')
doc.add_paragraph()

add_para('TIPS / TIPSS (Transjugular Intrahepatic Portosystemic Shunt):', bold=True)
add_bullet('Radiological procedure: channel created between portal vein and hepatic vein via jugular → IVC route')
add_bullet('Reduces portal pressure immediately')
add_bullet('Indications: variceal bleed uncontrolled by endoscopy; refractory variceal bleed; bridge to transplantation')
add_bullet('Complications: hepatic encephalopathy (30%), shunt thrombosis, liver failure')
doc.add_paragraph()

add_para('Surgical Options (Last resort):', bold=True)
add_table(
    ['Indication', 'Procedure'],
    [
        ['Non-variceal: Failed endoscopy, haemodynamic instability', 'Under-running of bleeding vessel (gastroduodenal artery for posterior DU); partial gastrectomy for malignant gastric ulcer'],
        ['Variceal: TIPS not available', 'Emergency portocaval shunt; Oesophageal transection (Sugiura-Futagawa procedure)'],
        ['End-stage liver disease', 'Liver transplantation — definitive treatment'],
    ]
)
doc.add_paragraph()

# ── COMPLICATIONS
add_heading('6. COMPLICATIONS OF UGIB', level=1)
add_table(
    ['Complication', 'Notes'],
    [
        ['Haemorrhagic shock', '>30% volume loss; MODS if untreated'],
        ['Aspiration pneumonia', 'Blood inhalation during vomiting / procedure'],
        ['Rebleeding', 'Highest in Forrest Ia (90%) and IIa (50%)'],
        ['Acute tubular necrosis', 'Renal hypoperfusion'],
        ['Hepatic encephalopathy', 'In cirrhosis — blood in gut = nitrogen load → ammonia toxicity'],
        ['Myocardial ischaemia', 'Hypoperfusion + tachycardia in elderly'],
    ]
)
doc.add_paragraph()

# ── SCORING GUIDE
add_heading("EXAMINER'S SCORING PATTERN (30 Marks)", level=1)
add_table(
    ['Section', 'Expected Marks'],
    [
        ['Definition + epidemiology + variceal key facts', '2'],
        ['Etiopathogenesis / causes (table with frequencies)', '6'],
        ['Clinical presentation (symptoms, haemodynamic status, signs)', '4'],
        ['Differential diagnosis (two-column list)', '2'],
        ['Investigations (Forrest classification especially)', '5'],
        ['Risk scores (Rockall + Blatchford)', '3'],
        ['Management (resuscitation + pharmacology + endoscopy)', '6'],
        ['Variceal specific management (terlipressin, banding, SB tube, TIPS)', '2'],
        ['TOTAL', '30'],
    ]
)
doc.add_paragraph()

add_heading('Mark-Winning Habits', level=2, color=(0x2E,0x75,0xB6))
tips = [
    'Write the FORREST CLASSIFICATION as a complete table with rebleed risk % — this scores maximum marks',
    'Write the ROCKALL SCORE as a structured table',
    'Clearly separate NON-VARICEAL vs VARICEAL management — examiners expect this distinction',
    '"Terlipressin is the ONLY vasoconstrictor with proven mortality benefit in variceal bleeding"',
    'Mention RESTRICTIVE transfusion strategy (target Hb 7-9 g/dL) — recent evidence-based concept',
    '"OGD within 24 hours; within 12 hours if haemodynamically unstable" — state this clearly',
    'Mallory-Weiss: history of VOMITING BEFORE haematemesis = discriminating feature',
    "Dieulafoy lesion and haemobilia (Quincke's triad) — uncommon but examiner's favourite discriminators",
]
for t in tips: add_bullet(t)

doc.add_paragraph()
p_src = doc.add_paragraph()
run_src = p_src.add_run("Sources: Sleisenger & Fordtran's Gastrointestinal and Liver Disease (p. 304-320) | Fischer's Mastery of Surgery 8th Ed. (p. 7711) | Bailey & Love's Short Practice of Surgery 28th Ed. (p. 1225)")
run_src.italic = True; run_src.font.size = Pt(9); run_src.font.color.rgb = RGBColor(0x70,0x70,0x70)

out_path = '/tmp/workspace/ms-surgery-notes/UGIB_30marks.docx'
doc.save(out_path)
print(f'Saved: {out_path}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()
section = doc.sections[0]
section.top_margin = Cm(2); section.bottom_margin = Cm(2)
section.left_margin = Cm(2.5); section.right_margin = Cm(2.5)
normal_style = doc.styles['Normal']
normal_style.font.name = 'Arial'; normal_style.font.size = Pt(11)
for i in range(1,4): doc.styles[f'Heading {i}'].font.name = 'Arial'

def add_heading(text, level=1, color=(0x1F,0x4E,0x79)):
    p = doc.add_heading(text, level=level)
    for run in p.runs: run.font.color.rgb = RGBColor(*color)
    return p

def add_para(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    run = p.add_run(text); run.bold=bold; run.italic=italic; run.font.size=Pt(size)
    if color: run.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def add_bullet(text):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    p.add_run(text).font.size = Pt(11); return p

def set_cell_bg(cell, hex_color):
    tc=cell._tc; tcPr=tc.get_or_add_tcPr(); shd=OxmlElement('w:shd')
    shd.set(qn('w:val'),'clear'); shd.set(qn('w:color'),'auto'); shd.set(qn('w:fill'),hex_color); tcPr.append(shd)

def add_table(headers, rows):
    table=doc.add_table(rows=1+len(rows),cols=len(headers)); table.style='Table Grid'
    hdr=table.rows[0].cells
    for i,h in enumerate(headers):
        hdr[i].text=h; set_cell_bg(hdr[i],'1F4E79')
        for para in hdr[i].paragraphs:
            for run in para.runs: run.bold=True; run.font.size=Pt(10); run.font.color.rgb=RGBColor(0xFF,0xFF,0xFF)
    for ri,row_data in enumerate(rows):
        cells=table.rows[ri+1].cells
        for ci,txt in enumerate(row_data):
            cells[ci].text=txt
            for para in cells[ci].paragraphs:
                for run in para.runs: run.font.size=Pt(10)
        if ri%2==0:
            for cell in cells: set_cell_bg(cell,'D6E4F0')
    return table

# COVER
p=doc.add_paragraph(); p.alignment=WD_ALIGN_PARAGRAPH.CENTER
run=p.add_run('MS GENERAL SURGERY — EXAM NOTES')
run.bold=True; run.font.size=Pt(18); run.font.color.rgb=RGBColor(0x1F,0x4E,0x79)
p2=doc.add_paragraph(); p2.alignment=WD_ALIGN_PARAGRAPH.CENTER
run2=p2.add_run('Anterior Abdominal Wall + Ventral & Incisional Hernias — 30-Mark Question')
run2.bold=True; run2.font.size=Pt(14); run2.font.color.rgb=RGBColor(0x2E,0x75,0xB6)
p3=doc.add_paragraph(); p3.alignment=WD_ALIGN_PARAGRAPH.CENTER
run3=p3.add_run('Sources: Thieme Atlas of Anatomy | Sabiston 21st Ed. | Fischer\'s Mastery of Surgery 8th Ed. | Mulholland & Greenfield\'s Surgery 7th Ed.')
run3.italic=True; run3.font.size=Pt(10); run3.font.color.rgb=RGBColor(0x70,0x70,0x70)
doc.add_paragraph()
pq=doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Describe anatomy of anterior abdominal wall. Write in detail etiopathogenesis, clinical features, diagnosis and management of Ventral Abdominal Hernias & Incisional Hernias."   [30 Marks]').bold=True
pq.runs[0].font.size=Pt(11); pq.runs[0].font.color.rgb=RGBColor(0x7B,0x22,0x00)
doc.add_paragraph()

# Embed anatomy image
img_url='https://cdn.orris.care/cdss_images/825857aa7456b3b110b877993641c0f96e0d9d402ce30c3e02c1d63ee92a82c0.png'
img_path='/tmp/workspace/ms-surgery-notes/abwall.png'
try:
    r=requests.get(img_url,timeout=15)
    if r.status_code==200:
        with open(img_path,'wb') as f: f.write(r.content)
        doc.add_picture(img_path,width=Inches(5.5))
        doc.paragraphs[-1].alignment=WD_ALIGN_PARAGRAPH.CENTER
        cap=doc.add_paragraph('Figure: Internal anatomy of anterior abdominal wall — Thieme Atlas of Anatomy')
        cap.alignment=WD_ALIGN_PARAGRAPH.CENTER; cap.runs[0].italic=True; cap.runs[0].font.size=Pt(9)
except: add_para('[Internal anatomy of anterior abdominal wall diagram — see Thieme Atlas Fig. 5.8]')
doc.add_paragraph()

# ── SECTION 1: ANATOMY
add_heading('1. SURGICAL ANATOMY OF ANTERIOR ABDOMINAL WALL',level=1)
add_para('EXAM TIP: Draw a cross-section diagram showing all 9 layers — this alone scores 4-5 marks.',bold=True,color=(0xC0,0x00,0x00))

add_heading('Layers (Superficial to Deep)',level=2,color=(0x2E,0x75,0xB6))
layers=[
    ('1. SKIN','Epidermis + dermis; flexible; Langer\'s lines run transversely in most of abdomen'),
    ("2. CAMPER'S FASCIA",'Superficial fatty layer of superficial fascia; continuous with fatty layer of perineum'),
    ("3. SCARPA'S FASCIA",'Deep membranous layer of superficial fascia; BELOW UMBILICUS ONLY; continues as Colles\' fascia in perineum'),
    ('4. EXTERNAL OBLIQUE MUSCLE/APONEUROSIS','Fibres run inferomedially; forms inguinal ligament; aponeurosis contributes to anterior rectus sheath'),
    ('5. INTERNAL OBLIQUE MUSCLE/APONEUROSIS','Fibres run superomedially; splits to form both layers of rectus sheath above arcuate line'),
    ('6. TRANSVERSUS ABDOMINIS MUSCLE/APONEUROSIS','Fibres run transversely; innermost flat muscle; contributes to posterior rectus sheath'),
    ('7. TRANSVERSALIS FASCIA','Deep fascia lining abdominal cavity; forms deep inguinal ring'),
    ('8. EXTRAPERITONEAL (PREPERITONEAL) FAT','Potential space used in preperitoneal hernia repairs (TEP, TAPP, Rives-Stoppa)'),
    ('9. PARIETAL PERITONEUM','Innermost layer; lines the abdominal cavity'),
]
add_table(['Layer','Details'], [(l[0],l[1]) for l in layers])
doc.add_paragraph()

add_heading('Muscles — Key Features',level=2,color=(0x2E,0x75,0xB6))
add_table(
    ['Muscle','Origin','Insertion','Action','Nerve'],
    [
        ['External oblique','Lower 8 ribs (outer surface)','Iliac crest, ASIS, inguinal ligament, linea alba','Flexion + contralateral rotation','T7-T12'],
        ['Internal oblique','ASIS, iliac crest, inguinal ligament','Pubic crest, linea alba, lower ribs','Flexion + ipsilateral rotation','T7-T12, L1'],
        ['Transversus abdominis','Lower 6 costal cartilages, thoracolumbar fascia, ASIS, iliac crest','Linea alba, pubic crest','Compresses abdomen','T7-T12, L1'],
        ['Rectus abdominis','Pubic symphysis, pubic crest','Xiphoid, costal cartilages 5-7','Flexion of trunk','T7-T12'],
    ]
)
doc.add_paragraph()

add_heading('Rectus Sheath — Critical Anatomy (DRAW THIS)',level=2,color=(0x2E,0x75,0xB6))
add_table(
    ['Level','Anterior Layer','Posterior Layer'],
    [
        ['ABOVE costal margin','External oblique aponeurosis only','Absent — muscle lies on costal cartilage'],
        ['Above Arcuate Line (umbilicus to mid-ASIS)','External oblique + anterior half of internal oblique','Posterior half of internal oblique + transversus abdominis'],
        ['Below Arcuate Line (Douglas)','ALL 3 aponeuroses (no posterior sheath)','Transversalis fascia ONLY'],
    ]
)
doc.add_paragraph()
add_bullet('ARCUATE LINE (Linea semicircularis / Douglas) = ~halfway between umbilicus and pubic symphysis')
add_bullet('Below arcuate line: posterior rectus sheath is ABSENT; inferior epigastric vessels pierce posterior wall here')
add_bullet('LINEA ALBA: fibrous raphe of fused aponeuroses; 1-3 cm wide above umbilicus; narrow below (site of epigastric hernia)')
add_bullet('LINEA SEMILUNARIS: lateral border of rectus sheath; site of rare Spigelian hernia')

add_heading('Peritoneal Folds (Internal Surface) — 5 Folds',level=2,color=(0x2E,0x75,0xB6))
add_para('These form the weak spots (fossae) for hernia formation — DRAW THIS diagram for the examiner:',bold=True)
add_table(
    ['Fold','Contains','Between Folds = Fossa = Hernia'],
    [
        ['Median umbilical fold (midline, 1)','Obliterated urachus','—'],
        ['Medial umbilical folds (paired, 2)','Obliterated umbilical arteries','Supravesical fossa (between median and medial)'],
        ['Lateral umbilical folds (paired, 2)','INFERIOR EPIGASTRIC VESSELS','Medial inguinal fossa = HESSELBACH\'S TRIANGLE (between medial and lateral) → Direct inguinal hernia; Lateral inguinal fossa = deep inguinal ring (lateral to lateral fold) → Indirect inguinal hernia'],
    ]
)
doc.add_paragraph()

add_heading('Blood Supply',level=2,color=(0x2E,0x75,0xB6))
add_table(
    ['Vessel','Origin','Notes'],
    [
        ['Superior epigastric artery','Internal thoracic artery','Runs within rectus muscle downward'],
        ['Inferior epigastric artery','External iliac artery','Runs within rectus muscle upward; pierces posterior sheath below arcuate line'],
        ['Anastomosis of both epigastrics','Within rectus muscle','Basis of TRAM flap for breast reconstruction'],
        ['Deep circumflex iliac artery','External iliac artery','Lateral wall supply'],
        ['Intercostal arteries (T7-T11)','Thoracic aorta','Upper abdominal wall'],
    ]
)
doc.add_paragraph()

add_heading('Nerve Supply',level=2,color=(0x2E,0x75,0xB6))
add_bullet('T7-T12 intercostal nerves: segmental supply to anterior abdominal wall')
add_bullet('L1: via ilioinguinal and iliohypogastric nerves (inguinal region)')
add_bullet('Run in plane BETWEEN internal oblique and transversus — at risk during lateral laparoscopic port placement')

add_heading('Weak Spots (Sites of Herniation)',level=2,color=(0x2E,0x75,0xB6))
add_table(
    ['Site','Hernia Type'],
    [
        ['Deep inguinal ring (lateral inguinal fossa)','Indirect inguinal hernia'],
        ["Hesselbach's triangle (medial inguinal fossa)",'Direct inguinal hernia'],
        ['Femoral ring (below inguinal ligament)','Femoral hernia'],
        ['Umbilicus','Umbilical / paraumbilical hernia'],
        ['Linea alba (epigastrium)','Epigastric hernia'],
        ['Linea semilunaris','Spigelian hernia'],
        ['Previous surgical scar','Incisional hernia'],
        ["Petit's / Grynfeltt's lumbar triangle",'Lumbar hernia'],
    ]
)
doc.add_paragraph()

# ── SECTION 2: VENTRAL HERNIAS
add_heading('2. VENTRAL ABDOMINAL HERNIAS — CLASSIFICATION',level=1)
add_para('Ventral hernia = protrusion of abdominal contents through a defect in the ANTERIOR abdominal wall (not inguinal/femoral region).',bold=True)
doc.add_paragraph()
add_table(
    ['Type','Location','Notes'],
    [
        ['Epigastric hernia','Linea alba between xiphoid and umbilicus','Contains extraperitoneal fat; small, painful; 80% multiple'],
        ['Umbilical hernia (congenital)','Umbilicus','80% close by age 2; surgery if persistent after age 4-5; ONLY hernia genetically programmed to close'],
        ['Paraumbilical hernia (adult)','Just above/below umbilicus','NEVER closes spontaneously; always requires surgery; more common in obese, multiparous women'],
        ['Spigelian hernia','Linea semilunaris','Interparietal/interstitial — OCCULT (not visible on surface); diagnosed on CT'],
        ['Diastasis recti','Midline separation of rectus abdominis','NOT a true hernia (no fascial defect); cosmetic bulge; no surgical urgency'],
        ['Incisional hernia','Previous surgical scar','Most common ventral hernia in adults; 33% after abdominal surgery'],
    ]
)
doc.add_paragraph()

# ── SECTION 3: INCISIONAL HERNIA
add_heading('3. INCISIONAL HERNIA — IN DETAIL',level=1)
add_para('Protrusion of abdominal contents through a defect at the site of a PREVIOUS SURGICAL INCISION.',bold=True)
add_bullet('Occurs in up to 33% of all patients undergoing abdominal surgery')
add_bullet('After surgery for malignancy: up to 41% at 2 years')
add_bullet('Most appear within the FIRST 2 YEARS of surgery')
doc.add_paragraph()

add_heading('Etiopathogenesis',level=2,color=(0x2E,0x75,0xB6))
add_para('A. Incision-Related Factors:',bold=True)
add_table(
    ['Factor','Detail'],
    [
        ['Midline incisions','HIGHEST RISK — poor vascular supply to linea alba → poor healing'],
        ['WOUND INFECTION (most important factor)','Increases risk 3-5x; fascial edge necrosis → gap formation'],
        ['Wound dehiscence','Precursor to incisional hernia in many cases'],
        ['Haematoma / seroma','Impairs wound healing by creating dead space'],
        ['Emergency surgery','Contaminated / inadequate closure'],
        ['Drain through wound','Creates additional weak point in fascia'],
    ]
)
doc.add_paragraph()
add_para('B. Suture/Technical Factors:',bold=True)
add_table(
    ['Factor','Detail'],
    [
        ['Excessive tension on closure','Ischaemia of wound edges → necrosis'],
        ['Suture material failure','Rapid absorbable sutures; knot slippage'],
        ['Inadequate bites','<1 cm from edge → dehiscence'],
        ['Inadequate suture:wound ratio','Ratio <4:1 doubles hernia risk — JENKINS RULE: ratio ≥4:1 required (1 cm bites, 1 cm apart)'],
        ['Suture absorbed before healing','Polyglycolic acid absorbed too early'],
    ]
)
doc.add_paragraph()
add_para('C. Patient-Related Systemic Factors:',bold=True)
add_table(
    ['Risk Factor','Mechanism'],
    [
        ['OBESITY (BMI >30)','↑ Intra-abdominal pressure; impaired wound healing'],
        ['Malnutrition / Hypoalbuminaemia','Impaired collagen synthesis'],
        ['Diabetes mellitus','Impaired neutrophil function + collagen synthesis'],
        ['SMOKING','Vasoconstriction → ischaemia; impaired collagen cross-linking'],
        ['Immunosuppression (steroids, chemotherapy)','Impaired healing response'],
        ['COPD / Chronic cough','Raised intra-abdominal pressure'],
        ['Jaundice / Renal failure','Impaired systemic healing'],
        ['Connective tissue disorders','Collagen synthesis defect'],
    ]
)
doc.add_paragraph()

add_heading('Clinical Features',level=2,color=(0x2E,0x75,0xB6))
add_para('Symptoms:',bold=True)
add_bullet('Reducible swelling/bulge at scar site — worse on straining, coughing, standing')
add_bullet('Pain/discomfort at site, especially on exertion')
add_bullet('Episodes of intestinal obstruction if intermittently irreducible')
add_bullet('Nausea/vomiting if bowel obstruction develops')
add_para('Signs:',bold=True)
add_bullet('Expansile cough impulse at scar site')
add_bullet('Reducible or irreducible swelling along scar')
add_bullet('Skin changes (chronic): thinning, ulceration, excoriation over large hernias')
add_bullet('Features of strangulation: tenderness, irreducibility, erythema, fever → SURGICAL EMERGENCY')

add_heading('Complications (applies to all hernias)',level=2,color=(0x2E,0x75,0xB6))
add_table(
    ['Complication','Details'],
    [
        ['1. Irreducibility (Incarceration)','Contents cannot be returned to abdomen; not yet compromised vascularly'],
        ['2. Obstruction','Bowel trapped in sac → intestinal obstruction'],
        ['3. STRANGULATION (most feared)','Blood supply cut off → ischaemia → gangrene; SURGICAL EMERGENCY'],
        ["4. Maydl's Hernia (W-hernia)",'Loop inside abdomen strangulates while exterior loop appears viable — very dangerous'],
        ['5. Inflammation','Secondary to ischaemia; local erythema, tenderness'],
    ]
)
doc.add_paragraph()

add_heading('Investigations / Diagnosis',level=2,color=(0x2E,0x75,0xB6))
add_table(
    ['Investigation','Role'],
    [
        ['Clinical examination','Expansile cough impulse; assess reducibility; measure defect (fingers)'],
        ['Ultrasound abdomen','First-line imaging; confirms hernia; identifies contents; measures defect'],
        ['CT abdomen (GOLD STANDARD for planning)','Measures defect dimensions; identifies loss of domain; detects occult Spigelian; adhesions'],
        ['MRI','Complex hernias near vascular structures'],
        ['Tanaka Index (CT-based)','Assesses abdominal wall compliance for loss-of-domain hernias — SHARP-EDGE DISCRIMINATOR'],
        ['Carbonell Equation (CT-based)','Predicts ability to achieve primary fascial closure in large hernias'],
    ]
)
doc.add_paragraph()

add_heading('Classification',level=2,color=(0x2E,0x75,0xB6))
add_para('EHS (European Hernia Society) Classification:',bold=True)
add_table(
    ['Location','Subdivisions','Width'],
    [
        ['Midline (M)','M1-Subxiphoid; M2-Epigastric; M3-Umbilical; M4-Infraumbilical; M5-Suprapubic','W1 = <4 cm'],
        ['Lateral (L)','L1-Subcostal; L2-Flank; L3-Iliac; L4-Lumbar','W2 = 4-10 cm'],
        ['Recurrent','Yes / No','W3 = >10 cm'],
    ]
)
doc.add_paragraph()
add_para('VHWG (Ventral Hernia Working Group) Classification — Wound Risk:',bold=True)
add_table(
    ['Grade','Description'],
    [
        ['Grade 1 — LOW RISK','No wound infection history; no comorbidities'],
        ['Grade 2 — COMORBID','Smoker, obese, diabetic, immunosuppressed, COPD'],
        ['Grade 3 — POTENTIALLY CONTAMINATED','Prior wound infection; stoma present; violation of GI tract'],
        ['Grade 4 — INFECTED','Infected mesh; septic wound dehiscence'],
    ]
)
doc.add_paragraph()

add_heading('Management',level=1,color=(0x1F,0x4E,0x79))

add_heading('Pre-operative Optimisation',level=2,color=(0x2E,0x75,0xB6))
preop=['Stop smoking — at least 6 weeks pre-op (most important modifiable risk factor)',
'Weight loss — target BMI <35',
'Optimise diabetes — HbA1c <8%',
'Nutritional support — albumin >30 g/L',
'Treat skin excoriation/ulceration over hernia',
'Progressive Preoperative Pneumoperitoneum (PPP) for loss-of-domain hernias: CO₂/air injected intraperitoneally daily for 2-4 weeks → expands abdominal cavity volume, stretches muscles → allows primary fascial closure',
'Botulinum toxin injection into lateral wall muscles (chemical component separation) — relaxes muscles, facilitates medialization']
for item in preop: add_bullet(item)
doc.add_paragraph()

add_heading('A. Open Surgical Repair',level=2,color=(0x2E,0x75,0xB6))
add_para('1. Primary Suture Repair:',bold=True)
add_bullet('Only for small defects (<2 cm), low-risk patients, VHWG Grade 1')
add_bullet('Mass closure with slowly absorbable/non-absorbable suture; Jenkins rule (ratio ≥4:1)')
add_bullet('RECURRENCE 20-63% — hence mesh must be added for defects >2 cm')
doc.add_paragraph()
add_para('2. Mesh-based Repair — Four Mesh Positions:',bold=True,color=(0xC0,0x00,0x00))
add_table(
    ['Position','Description','Advantages','Disadvantages'],
    [
        ['ONLAY','Mesh placed anterior to anterior rectus sheath; fascia closed beneath','Extraperitoneal; avoids adhesions','High SSI and infection rates; highest recurrence after sublay'],
        ['INLAY (Bridging)','Mesh bridges defect WITHOUT fascial closure','Used when primary closure impossible','HIGHEST RECURRENCE of all positions; poor functional outcomes — AVOID'],
        ['SUBLAY / Retromuscular (GOLD STANDARD)','Mesh posterior to rectus muscle, anterior to posterior rectus sheath (Rives-Stoppa position)','Best fixation; no adhesions; lowest recurrence (5-10%); no SSI risk','More dissection required'],
        ['UNDERLAY (IPOM — Intraperitoneal)','Mesh inside peritoneal cavity','Simple; suited for laparoscopic approach','Adhesion risk; needs composite mesh with anti-adhesion coating'],
    ]
)
doc.add_paragraph()
add_para('Rives-Stoppa Retromuscular Repair = GOLD STANDARD:',bold=True)
add_bullet('Mesh in retromuscular space (between rectus muscle and posterior rectus sheath)')
add_bullet('Requires fascial closure anterior to mesh')
add_bullet('Low recurrence (5-10%); low infection rate; best functional outcome')
doc.add_paragraph()

add_heading('Component Separation Techniques (HIGH-YIELD)',level=2,color=(0x2E,0x75,0xB6))
add_para('Used when fascial closure CANNOT be achieved by primary suturing in large defects:',bold=True,color=(0xC0,0x00,0x00))
add_table(
    ['Technique','Description','Medialization','Disadvantage'],
    [
        ['ANTERIOR Component Separation (Ramirez, 1990)','External oblique aponeurosis divided 2 cm lateral to linea semilunaris; space between external and internal oblique developed; posterior rectus sheath incised','3-10 cm per side','Large subcutaneous skin flaps → high wound complications; skin flap necrosis'],
        ['POSTERIOR Component Separation with TAR (Transversus Abdominis Release)','Posterior rectus sheath incised → transversus abdominis divided → access to retromuscular space and retroperitoneal plane; no large skin flaps','10-15 cm per side (MORE than anterior)','More complex dissection; longer operating time; NOW PREFERRED over anterior'],
    ]
)
doc.add_paragraph()
add_para('TAR is the current preferred technique for large complex incisional hernias — more medialization, fewer wound complications.',bold=True)

add_heading('B. Laparoscopic / Robotic Ventral Hernia Repair',level=2,color=(0x2E,0x75,0xB6))
add_table(
    ['Approach','Technique','Advantages','Disadvantages'],
    [
        ['Laparoscopic IPOM','3 ports; reduce hernia contents; composite mesh fixed intraperitoneally with tacks/sutures; defect may or may not be closed','Fewer SSIs; faster recovery; less post-op pain','Bridging if defect not closed → higher recurrence; adhesion risk'],
        ['IPOM-Plus','Laparoscopic defect closure BEFORE mesh placement','Better outcomes vs standard IPOM','More technically demanding'],
        ['Robotic TAR','Posterior component separation + retromuscular mesh via robotic platform; avoids open laparotomy','Minimally invasive + best repair; 3D HD vision; wristed instruments','Longer operative time; higher cost; limited availability'],
    ]
)
doc.add_paragraph()

add_heading('Mesh Types',level=2,color=(0x2E,0x75,0xB6))
add_table(
    ['Type','Material','Indication'],
    [
        ['Synthetic non-absorbable (PP)','Polypropylene (Prolene)','Clean fields; most widely used; lightweight preferred'],
        ['Synthetic (Polyester)','Mersilene','Retromuscular (Sublay) position'],
        ['Composite mesh','PP + anti-adhesion coating (PTFE/PDS/Sepra film)','Intraperitoneal (IPOM) — prevents bowel adhesions'],
        ['Biological mesh','Porcine/bovine collagen (Strattice, Permacol)','Contaminated/infected fields; VHWG Grade 3-4'],
        ['Absorbable synthetic','Vicryl, PDS','Temporary bridging in contaminated field; bridge to definitive repair'],
    ]
)
doc.add_paragraph()

add_heading('Strangulated Hernia — Emergency Management',level=2,color=(0x2E,0x75,0xB6))
emg=['Emergency surgery; DO NOT delay',
'Reduce hernia; assess bowel viability',
'If viable bowel: reduce + hernia repair',
'If non-viable bowel: resection + primary anastomosis OR stoma formation',
'AVOID synthetic mesh in contaminated/infected fields — use biological mesh or delayed repair',
'IV antibiotics + aggressive resuscitation pre-op']
for e in emg: add_bullet(e)
doc.add_paragraph()

add_heading('Loss of Domain Hernias',level=2,color=(0x2E,0x75,0xB6))
lod=['Definition: herniated viscera exceeds capacity of abdominal cavity to re-accommodate',
'Tanaka index + Carbonell equation used for planning on CT',
'Pre-op: Progressive Preoperative Pneumoperitoneum (PPP) for 2-4 weeks',
'Botulinum toxin injection to lateral wall muscles (chemical component separation)',
'Surgical repair: TAR + large retromuscular mesh',
'High morbidity/mortality — refer to specialist abdominal wall reconstruction centres']
for l in lod: add_bullet(l)
doc.add_paragraph()

add_heading('Complications of Repair',level=2,color=(0x2E,0x75,0xB6))
add_table(
    ['Complication','Notes'],
    [
        ['SSI (most common)','Surface cellulitis vs deep mesh infection; may require mesh explantation'],
        ['Seroma','Fluid in dead space; especially after large dissection; usually resolves spontaneously'],
        ['Mesh infection','May require explantation; use biological mesh in contaminated cases'],
        ['Recurrence','Highest with onlay/bridging; lowest with retromuscular (Rives-Stoppa)'],
        ['Adhesive intestinal obstruction','Post-laparotomy or intraperitoneal mesh'],
        ['Enterocutaneous fistula','Rare; mesh erosion into bowel'],
        ['Abdominal compartment syndrome','After repair of massive hernia — raised IAP → respiratory compromise'],
        ['Haematoma','Early post-op'],
        ['Chronic pain','Late; especially post-mesh tack fixation'],
    ]
)
doc.add_paragraph()

add_heading('Recent Advances',level=1,color=(0x1F,0x4E,0x79))
ra=['Robotic TAR — minimally invasive posterior component separation with retromuscular mesh',
'Botulinum toxin injection — chemical component separation pre-operatively',
'IPOM-Plus — laparoscopic fascial closure before mesh placement',
'ERAS (Enhanced Recovery After Surgery) protocol for hernia repair',
'Biological mesh for Grade 3-4 VHWG contaminated fields',
'3D-printed custom mesh — fitted to CT-measured defect dimensions',
'eTEP (Extended Totally ExtraPeritoneal) repair — avoids peritoneal cavity entirely',
'SCOLA (SubCutaneous OnLay Laparoscopic Approach) — laparoscopic onlay mesh']
for r in ra: add_bullet(r)
doc.add_paragraph()

add_heading("EXAMINER'S SCORING PATTERN (30 Marks)",level=1)
add_table(
    ['Section','Expected Marks'],
    [
        ['Anatomy of anterior abdominal wall (layers + muscles + rectus sheath)','8'],
        ['Diagram: cross-section of layers + posterior surface folds/fossae','3'],
        ['Types of ventral hernia (classification)','2'],
        ['Etiopathogenesis of incisional hernia (patient + technical factors)','4'],
        ['Clinical features + complications','3'],
        ['Investigations (CT + EHS/VHWG classification)','2'],
        ['Management (mesh positions + component separation + laparoscopic)','7'],
        ['Recent advances (TAR, botox, robotic, ERAS)','1'],
        ['TOTAL','30'],
    ]
)
doc.add_paragraph()

add_heading('Mark-Winning Habits',level=2,color=(0x2E,0x75,0xB6))
tips=['Draw the CROSS-SECTION of anterior abdominal wall showing all 9 layers — mandatory diagram',
'Draw RECTUS SHEATH at 3 levels (above costal margin, above arcuate line, below arcuate line)',
'Draw 5 PERITONEAL FOLDS on internal surface and label fossae + hernia types',
"Write JENKINS RULE: suture:wound ratio ≥4:1 (1 cm bites, 1 cm apart) — examiner's favourite fact",
'Clearly separate 4 MESH POSITIONS in a table; name Rives-Stoppa as gold standard',
'State RAMIREZ (1990) anterior component separation + TAR as modern preferred alternative',
'Tanaka index + Carbonell equation — always mention for loss-of-domain hernias',
'VHWG Grade 4 = avoid synthetic mesh → biological mesh required',
'TAR provides 10-15 cm medialization per side vs 3-10 cm for anterior CS']
for t in tips: add_bullet(t)
doc.add_paragraph()
p_src=doc.add_paragraph()
run_src=p_src.add_run("Sources: Thieme Atlas of Anatomy (p. 233) | Sabiston Textbook of Surgery (p. 1104-1130) | Fischer's Mastery of Surgery 8th Ed. (p. 5941) | Mulholland & Greenfield's Surgery 7th Ed. (p. 3721, 3751)")
run_src.italic=True; run_src.font.size=Pt(9); run_src.font.color.rgb=RGBColor(0x70,0x70,0x70)

out_path='/tmp/workspace/ms-surgery-notes/Abdominal_Wall_Hernia_30marks.docx'
doc.save(out_path)
print(f'Saved: {out_path}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests, os

doc = Document()
section = doc.sections[0]
section.top_margin = Cm(2); section.bottom_margin = Cm(2)
section.left_margin = Cm(2.5); section.right_margin = Cm(2.5)
doc.styles['Normal'].font.name = 'Arial'
doc.styles['Normal'].font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def add_heading(text, level=1, color=(0x1F, 0x4E, 0x79)):
    p = doc.add_heading(text, level=level)
    for run in p.runs:
        run.font.color.rgb = RGBColor(*color)
    return p

def add_para(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = bold; run.italic = italic; run.font.size = Pt(size)
    if color:
        run.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def add_bullet(text):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    p.add_run(text).font.size = Pt(11)
    return p

def set_cell_bg(cell, hex_color):
    tc = cell._tc; tcPr = tc.get_or_add_tcPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear'); shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), hex_color); tcPr.append(shd)

def add_table(headers, rows):
    table = doc.add_table(rows=1+len(rows), cols=len(headers))
    table.style = 'Table Grid'
    hdr = table.rows[0].cells
    for i, h in enumerate(headers):
        hdr[i].text = h
        set_cell_bg(hdr[i], '1F4E79')
        for para in hdr[i].paragraphs:
            for run in para.runs:
                run.bold = True; run.font.size = Pt(10)
                run.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
    for ri, row_data in enumerate(rows):
        cells = table.rows[ri+1].cells
        for ci, txt in enumerate(row_data):
            cells[ci].text = txt
            for para in cells[ci].paragraphs:
                for run in para.runs:
                    run.font.size = Pt(10)
        if ri % 2 == 0:
            for cell in cells:
                set_cell_bg(cell, 'D6E4F0')
    return table

def embed_image(url, path, width=Inches(5.0), caption=None):
    try:
        r = requests.get(url, timeout=15)
        if r.status_code == 200:
            with open(path, 'wb') as f: f.write(r.content)
            doc.add_picture(path, width=width)
            doc.paragraphs[-1].alignment = WD_ALIGN_PARAGRAPH.CENTER
            if caption:
                cap = doc.add_paragraph(caption)
                cap.alignment = WD_ALIGN_PARAGRAPH.CENTER
                cap.runs[0].italic = True; cap.runs[0].font.size = Pt(9)
    except Exception as e:
        add_para(f'[Image could not be loaded: {caption}]', italic=True, color=(0x70,0x70,0x70))

# ═══ COVER ═══
p = doc.add_paragraph(); p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run('MS GENERAL SURGERY — EXAM NOTES')
run.bold = True; run.font.size = Pt(18); run.font.color.rgb = RGBColor(0x1F, 0x4E, 0x79)
p2 = doc.add_paragraph(); p2.alignment = WD_ALIGN_PARAGRAPH.CENTER
run2 = p2.add_run('Varicose Veins of Lower Limb — 30-Mark Question')
run2.bold = True; run2.font.size = Pt(14); run2.font.color.rgb = RGBColor(0x2E, 0x75, 0xB6)
p3 = doc.add_paragraph(); p3.alignment = WD_ALIGN_PARAGRAPH.CENTER
run3 = p3.add_run("Sources: Sabiston 21st Ed. | Mulholland & Greenfield's Surgery 7th Ed. | Current Surgical Therapy 14th Ed.")
run3.italic = True; run3.font.size = Pt(10); run3.font.color.rgb = RGBColor(0x70, 0x70, 0x70)
doc.add_paragraph()
pq = doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Describe surgical anatomy of veins of lower limb. Discuss etiopathogenesis, clinical features, investigations and management of varicose veins."   [30 Marks]').bold = True
pq.runs[0].font.size = Pt(11); pq.runs[0].font.color.rgb = RGBColor(0x7B, 0x22, 0x00)
doc.add_paragraph()

# Anatomy image
embed_image(
    'https://cdn.orris.care/cdss_images/GLGCA_4589262_1766503592460_b440cb75-9083-4ade-8d6a-6cd44927a52b_6dec4211-ea02-4aff-a743-cf29d8f5de27.png',
    '/tmp/workspace/ms-surgery-notes/vv_anatomy.png',
    width=Inches(5.0),
    caption='Figure: Superficial veins of lower limb — Great saphenous vein, Small saphenous vein, Giacomini vein, Accessory saphenous veins (from Textbook Library)'
)
doc.add_paragraph()

# ═══ SECTION 1: ANATOMY ═══
add_heading('1. SURGICAL ANATOMY OF VEINS OF THE LOWER LIMB', level=1)
add_para('EXAM TIP: Draw a diagram of the venous system of the lower limb — scores 3-4 marks immediately. Mark GSV, SSV, Giacomini vein, perforators, SFJ and SPJ.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

add_heading('A. Deep Veins', level=2, color=(0x2E,0x75,0xB6))
add_para('Deep veins carry 85-90% of blood from the lower limb. They follow the arterial pattern and run within the deep fascia.', bold=False)
add_table(
    ['Level', 'Vein'],
    [
        ['Foot', 'Plantar veins → Posterior tibial veins'],
        ['Leg (3 pairs)', 'Anterior tibial veins + Posterior tibial veins + Peroneal veins'],
        ['Popliteal fossa', 'POPLITEAL VEIN (confluence of tibial veins above knee)'],
        ['Thigh', 'FEMORAL VEIN (femoral + profunda femoris → common femoral)'],
        ['Groin', 'COMMON FEMORAL VEIN → External iliac vein → IVC'],
        ['Soleus sinusoids', 'Large intramuscular venous sinuses in soleus muscle — SITE OF DVT INITIATION'],
    ]
)
doc.add_paragraph()

add_heading('B. Superficial Veins', level=2, color=(0x2E,0x75,0xB6))
add_heading('1. Great Saphenous Vein (GSV) — longest vein in the body', level=3, color=(0x1F,0x50,0x90))
add_table(
    ['Feature', 'Detail'],
    [
        ['Origin', 'Medial end of dorsal venous arch of the foot'],
        ['Course', '1 cm ANTERIOR to medial malleolus → medial border of tibia → medial side of knee → medial thigh'],
        ['Termination', 'Pierces cribriform fascia (saphenous opening/fossa ovalis) → drains into COMMON FEMORAL VEIN at saphenofemoral junction (SFJ)'],
        ['SFJ location', '3.5 cm BELOW AND LATERAL to the pubic tubercle — critical landmark for surgery'],
        ['Number of valves', '8-10 valves; MOST IMPORTANT = saphenofemoral valve (most proximal)'],
        ['Nerve relation', 'SAPHENOUS NERVE (branch of femoral nerve) accompanies GSV in the leg — injury → medial calf paraesthesia (avoid stripping below knee)'],
        ['Tributaries at SFJ', 'Superficial epigastric, Superficial external pudendal, Superficial circumflex iliac, Anterior thigh, Posteromedial vein — ALL must be ligated at Trendelenburg op'],
    ]
)
doc.add_paragraph()
add_heading('2. Small (Short) Saphenous Vein (SSV)', level=3, color=(0x1F,0x50,0x90))
add_table(
    ['Feature', 'Detail'],
    [
        ['Origin', 'Lateral end of dorsal venous arch of the foot'],
        ['Course', 'BEHIND lateral malleolus → midline of back of calf → pierces deep fascia in popliteal fossa'],
        ['Termination', 'Drains into POPLITEAL VEIN at saphenopopliteal junction (SPJ)'],
        ['SPJ level', 'Variable — usually 5 cm above popliteal crease; ALWAYS confirm by duplex before surgery'],
        ['Nerve relation', 'SURAL NERVE accompanies SSV — injury → lateral foot paraesthesia'],
    ]
)
add_bullet('GIACOMINI VEIN: Connects SSV to GSV across the posterior thigh — source of recurrent varicosities if missed at surgery')
add_bullet('Anterior and Posterior ACCESSORY SAPHENOUS VEINS: Branch from GSV in thigh — must identify on duplex')
doc.add_paragraph()

add_heading('C. Perforating (Communicating) Veins — HIGH YIELD', level=2, color=(0x2E,0x75,0xB6))
add_para('Connect superficial to deep veins through the deep fascia. Contain bicuspid valves directing flow INWARD (superficial to deep). When incompetent: outward flow → superficial hypertension.', bold=False)
add_table(
    ['Named Perforator', 'Level', 'Deep Vein', 'Clinical Significance'],
    [
        ["COCKETT'S PERFORATORS (I, II, III)", '6, 13.5, 18 cm above medial malleolus', 'Posterior tibial veins', 'INCOMPETENCE → MEDIAL GAITER ULCERS (most important clinically)'],
        ["BOYD'S PERFORATOR", 'Upper medial calf, just below knee', 'Tibial veins', 'Commonly incompetent; contributes to calf varicosities'],
        ["DODD'S PERFORATORS", 'Mid-thigh (Hunter canal)', 'Femoral vein', 'Thigh varicosities'],
        ['HUNTERIAN PERFORATOR', 'Upper thigh (Hunter canal)', 'Femoral vein', 'Proximal GSV incompetence'],
    ]
)
doc.add_paragraph()

add_heading('D. Venous Valves', level=2, color=(0x2E,0x75,0xB6))
add_bullet('Bicuspid, semilunar valves')
add_bullet('Direct flow: DISTAL → PROXIMAL in axial veins; SUPERFICIAL → DEEP via perforators')
add_bullet('Absent in: common iliac veins, inferior vena cava, veins <1 mm diameter (telangiectasias)')
add_bullet('GSV has 8-10 valves; most important = saphenofemoral valve')
doc.add_paragraph()

add_heading('E. Physiology of Venous Return', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Mechanism', 'Detail'],
    [
        ['1. Calf Muscle Pump ("peripheral heart")', 'Contraction of soleus + gastrocnemius compresses deep veins → 300 mmHg in deep system; 100-150 mmHg in superficial on exercise → propels blood proximally'],
        ['2. Vis-a-tergo (arterial inflow)', 'Residual arterial pressure drives venous blood proximally'],
        ['3. Respiratory pump', 'Inspiration lowers intrathoracic pressure → increases venous return'],
        ['4. Venous valves', 'Prevent reflux during muscle pump relaxation; protect superficial system from deep pressure'],
    ]
)
doc.add_paragraph()
add_para('Ambulatory Venous Pressure (AVP):', bold=True)
add_bullet('Standing AVP at ankle = 80-90 mmHg (pure hydrostatic pressure)')
add_bullet('On walking: AVP falls to 20-25 mmHg (calf pump active) = VENOUS PRESSURE RESERVE')
add_bullet('In venous insufficiency: AVP does NOT fall on exercise → sustained venous hypertension')
add_bullet('Skin changes appear at AVP >35 mmHg; virtually certain at AVP >90 mmHg')
add_bullet('Source: Current Surgical Therapy 14th Ed., p.1235')
doc.add_paragraph()

# ═══ SECTION 2: DEFINITION & CLASSIFICATION ═══
add_heading('2. VARICOSE VEINS — DEFINITION & EPIDEMIOLOGY', level=1)
add_para('DEFINITION: Tortuous, dilated, elongated superficial veins of the lower limb with incompetent valves, diameter >3 mm when standing.', bold=True)
add_table(
    ['Vein Type', 'Diameter', 'Location'],
    [
        ['Telangiectasias (spider veins)', '<1 mm', 'Intradermal'],
        ['Reticular veins', '1-3 mm', 'Subdermal / subcutaneous'],
        ['VARICOSE VEINS', '>3 mm', 'Subcutaneous, palpable, tortuous'],
    ]
)
doc.add_paragraph()
add_para('Epidemiology:', bold=True)
add_bullet('18% of general population have varicose veins; 21.7% have telangiectasias/reticular veins')
add_bullet('Active venous ulcers: 0.7% of population')
add_bullet('Female:Male = 3:1 (gender difference narrows with age)')
add_bullet('Cost of venous ulcer care: $1.5-3 billion per year (USA)')
add_bullet('Sources: Mulholland & Greenfield p. 5217; Sabiston p. 2399')
doc.add_paragraph()

# ═══ SECTION 3: ETIOPATHOGENESIS ═══
add_heading('3. ETIOPATHOGENESIS', level=1)
add_heading('Classification by Aetiology', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Type', 'Frequency', 'Description'],
    [
        ['PRIMARY varicose veins', '70-80%', 'Intrinsic valvular insufficiency; genetic predisposition; no identifiable cause'],
        ['SECONDARY varicose veins', '15-25%', 'DVT → post-thrombotic syndrome; pelvic tumour; AV fistula causing secondary venous hypertension'],
        ['CONGENITAL varicose veins', '<5%', 'Klippel-Trenaunay syndrome (port wine stain + limb hypertrophy + varicosities); AV fistula; Ehlers-Danlos syndrome'],
    ]
)
doc.add_paragraph()

add_heading('Risk Factors for Primary Varicose Veins', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Risk Factor', 'Mechanism'],
    [
        ['POSITIVE FAMILY HISTORY', 'Autosomal dominant with incomplete penetrance; defective collagen + elastin in vein wall'],
        ['FEMALE GENDER', 'Progesterone relaxes smooth muscle → venous dilatation; oestrogen effects on vein wall'],
        ['PREGNANCY (multiparity)', 'Raised intra-abdominal pressure; hormonal relaxation of vein wall; increased blood volume'],
        ['PROLONGED STANDING', 'Sustained hydrostatic pressure → progressive valve incompetence'],
        ['OBESITY', 'Raised intra-abdominal pressure + increased venous pressure; impaired calf pump'],
        ['ADVANCING AGE', 'Degenerative changes in vein wall and valve leaflets'],
        ['OCCUPATION', 'Hairdressers, surgeons, teachers — prolonged standing'],
        ['CONSTIPATION', 'Raised intra-abdominal pressure transmitted to iliac veins'],
    ]
)
doc.add_paragraph()

add_heading('Pathophysiology — Two Theories', level=2, color=(0x2E,0x75,0xB6))
add_para('1. DESCENDING THEORY (Valve First — most accepted):', bold=True, color=(0x1F,0x4E,0x79))
add_bullet('Primary valvular weakness at SFJ (proximal valve fails first)')
add_bullet('Reflux of blood into GSV → raised pressure transmitted distally')
add_bullet('Progressive distal valve failure → varicosity formation')
add_bullet('Evidence: >70% of varicosities show incompetent SFJ on duplex')
add_para('2. ASCENDING THEORY (Vein Wall First):', bold=True, color=(0x1F,0x4E,0x79))
add_bullet('Primary intrinsic weakness of vein wall (connective tissue / collagen defect)')
add_bullet('Vein wall dilates → valve cusps separate → secondary valvular incompetence')
add_bullet('Perforator incompetence → superficial hypertension')
doc.add_paragraph()
add_para('Common Pathway of Pathological Progression:', bold=True)
add_table(
    ['Step', 'Event'],
    [
        ['1', 'Valvular incompetence (SFJ / SPJ / perforators) → reversal of flow (reflux)'],
        ['2', 'Superficial venous hypertension → raised capillary pressure'],
        ['3', 'Capillary leakage → plasma proteins + RBCs leak into dermis'],
        ['4', 'Fibrin cuffs form around capillaries (Browse & Burnand Fibrin Cuff Theory) → impaired O₂ diffusion'],
        ['5', 'White cell trapping → inflammatory mediators → tissue damage'],
        ['6', 'Haemosiderin deposition → pigmentation → lipodermatosclerosis → venous ulceration'],
    ]
)
doc.add_paragraph()

# ═══ SECTION 4: CLINICAL FEATURES ═══
add_heading('4. CLINICAL FEATURES', level=1)
add_heading('Symptoms', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Symptom', 'Notes'],
    [
        ['Prominent dilated veins', 'Aching/throbbing; worse on prolonged standing; relieved by elevation'],
        ['Ankle oedema', 'Pitting; worse in evening; venous hypertension → capillary leakage'],
        ['Aching / heaviness', 'In calf or thigh; worse at end of day'],
        ['Itching / eczema', 'Over varicosities; varicose (stasis) eczema'],
        ['Cramps', 'Nocturnal; common early symptom'],
        ['Restless leg', 'Especially at night; common presenting complaint'],
        ['Cosmetic concern', 'Major reason for presentation — especially in women'],
    ]
)
doc.add_paragraph()
add_heading('Signs', level=2, color=(0x2E,0x75,0xB6))
add_para('Inspection:', bold=True)
add_bullet('Dilated, tortuous, bluish veins — medial thigh (GSV) or posterior calf (SSV)')
add_bullet('Ankle pigmentation (haemosiderin deposition)')
add_bullet('Lipodermatosclerosis ("champagne bottle leg" — brawny induration of lower calf)')
add_bullet('Varicose eczema (stasis dermatitis — itching, weeping)')
add_bullet('Atrophie blanche (white stellate scars around medial malleolus; painful)')
add_bullet('CORONA PHLEBETATICA — fan-shaped intradermal telangiectasias at medial malleolus = CEAP C4c')
add_bullet('Venous ulcer — MEDIAL GAITER AREA (Cockett perforators zone) — 2/3 of all leg ulcers')
add_para('Palpation:', bold=True)
add_bullet('Soft, compressible, reducible varicosities')
add_bullet('SAPHENA VARIX — soft fluctuant swelling at SFJ in groin; transmits cough impulse; must distinguish from femoral hernia')
add_bullet('Flabby induration of lipodermatosclerosis')
doc.add_paragraph()

add_heading('Clinical Tests', level=2, color=(0x2E,0x75,0xB6))
add_para('(Now largely superseded by duplex — but list BOTH traditional tests AND duplex for full marks)', bold=True, color=(0xC0,0x00,0x00))
add_table(
    ['Test', 'Technique', 'Positive Finding', 'Significance'],
    [
        ['TRENDELENBURG TEST\n(SFJ competence)', 'Supine; empty veins by elevation; compress SFJ; ask patient to stand.\nStep 1: release compress — observe fill pattern.\nStep 2: compress not released — fill from below?', 'Step 1: rapid fill from above = incompetent SFJ.\nStep 2: fill from below = incompetent perforators', 'Localises level of incompetence — SFJ vs perforators'],
        ["PERTHE'S TEST\n(Deep vein patency)", 'Apply tourniquet at upper thigh; ask patient to walk vigorously for 5 minutes', 'Veins INCREASE in size / patient gets pain = deep vein OBSTRUCTION', 'POSITIVE = CONTRAINDICATION TO SURGERY on superficial veins'],
        ['MORRISSEY COUGH TEST', 'Finger on SFJ; patient coughs', 'Palpable thrill at SFJ', 'Incompetent sapheno-femoral junction'],
        ['MULTIPLE TOURNIQUET TEST', 'Tourniquets at multiple levels; patient stands', 'Fills between tourniquets = perforator incompetence at that level', 'Localises incompetent perforators'],
        ["FEGAN'S TEST", 'Mark sites of tenderness along perforator lines with patient standing', 'Varicosities emerge from fascial defects at tender points', 'Confirms perforator sites for targeted surgery'],
    ]
)
doc.add_paragraph()

# ═══ SECTION 5: INVESTIGATIONS ═══
add_heading('5. INVESTIGATIONS', level=1)
add_table(
    ['Investigation', 'Purpose / Detail'],
    [
        ['DUPLEX ULTRASONOGRAPHY\n(GOLD STANDARD)', 'Identifies sites of reflux (SFJ, SPJ, perforators); maps GSV diameter; confirms deep vein patency. Done with patient STANDING. Pathological reflux = reversal >500 ms (superficial/perforators); >1000 ms (deep veins). Vein diameter >5 mm = significant. Essential before any intervention.'],
        ['Hand-held Doppler', 'Bedside assessment of SFJ, SPJ competence; quick screen in outpatient setting'],
        ['Ascending Venography', 'Deep vein anatomy when DVT suspected; now largely replaced by CT/MR venography'],
        ['Air Plethysmography (APG)', 'Objective measurement of calf pump function and venous reflux volume'],
        ['CT Venography / MR Venography', 'Pelvic vein assessment (May-Thurner syndrome; pelvic varicosities; iliac vein obstruction)'],
    ]
)
doc.add_paragraph()

add_heading('CEAP Classification — 2020 Update (FULL TABLE)', level=2, color=(0x2E,0x75,0xB6))
add_para('CEAP = Clinical + Etiologic + Anatomic + Pathophysiologic. Introduced 1994; revised 2004; updated 2020.', bold=True)
add_table(
    ['Component', 'Grade', 'Description'],
    [
        ['C — Clinical', 'C0', 'No visible or palpable signs of venous disease'],
        ['', 'C1', 'Telangiectasias or reticular veins'],
        ['', 'C2', 'Varicose veins (>3 mm)'],
        ['', 'C2r', 'Recurrent varicose veins (NEW in 2020)'],
        ['', 'C3', 'Oedema'],
        ['', 'C4a', 'Pigmentation or eczema'],
        ['', 'C4b', 'Lipodermatosclerosis or atrophie blanche'],
        ['', 'C4c', 'Corona phlebetatica (NEW in 2020)'],
        ['', 'C5', 'Healed venous ulcer'],
        ['', 'C6', 'Active venous ulcer'],
        ['', 'C6r', 'Recurrent active venous ulcer (NEW in 2020)'],
        ['E — Etiologic', 'Ep = Primary; Es = Secondary; Ec = Congenital; En = Not identified', ''],
        ['A — Anatomic', 'As = Superficial; Ad = Deep; Ap = Perforator; An = Not identified', ''],
        ['P — Pathophysiologic', 'Pr = Reflux; Po = Obstruction; Pr,o = Both; Pn = Not identified', ''],
    ]
)
add_bullet('Source: Lurie F et al. J Vasc Surg Venous Lymphat Disord. 2020;8:342–352 (Current Surgical Therapy 14th Ed.)')
doc.add_paragraph()

# ═══ SECTION 6: MANAGEMENT ═══
add_heading('6. MANAGEMENT', level=1)

add_heading('A. Conservative (Non-Operative) Management', level=2, color=(0x2E,0x75,0xB6))
add_para('Indications: Mild symptoms; patient unfit for surgery; deep vein obstruction (positive Perthe test); patient preference.', bold=True)
add_table(
    ['Measure', 'Detail'],
    [
        ['COMPRESSION HOSIERY\n(Cornerstone of conservative management)', 'Class I: 14-17 mmHg → telangiectasias/reticular veins\nClass II: 18-24 mmHg → varicose veins + oedema\nClass III: 25-35 mmHg → active venous ulcer\nElastic = constant pressure (Tubigrip, stockings)\nInelastic = more effective for CVI (more dynamic pressure during exercise) — Unna boot, 4-layer bandage\nCompress median 30-40 mmHg → narrowing of superficial veins'],
        ['Leg elevation', 'Elevate >30 cm above heart; reduces AVP; 33 min/day significantly reduces ulcer recurrence'],
        ['Lifestyle changes', 'Weight loss; avoid prolonged standing; regular walking (activates calf pump)'],
        ['Daflon (micronised purified flavonoid fraction)', 'Reduces capillary permeability and inflammation; symptomatic relief; aids venous ulcer healing'],
    ]
)
doc.add_paragraph()
add_para('Compression with concomitant arterial disease: SAFE if ABPI ≥0.8. MODIFIED (lower pressure) if ABPI 0.5-0.8. CONTRAINDICATED if ABPI <0.5 or ankle pressure <60 mmHg.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

add_heading('B. Endovenous Thermal Ablation — FIRST-LINE Treatment (NICE 2013 CG168)', level=2, color=(0x2E,0x75,0xB6))
add_para('Principle: Apply thermal energy to vein wall → endothelial + collagen damage → vein closure → fibrosis + resorption.', bold=True)
doc.add_paragraph()

add_para('1. ENDOVENOUS LASER ABLATION (EVLA / EVLT):', bold=True, color=(0x1F,0x4E,0x79))
add_bullet('First introduced: CARLOS BONÉ, 1999 — sharp-edge discriminator')
add_bullet('Energy: 980 nm or 1470 nm laser wavelength')
add_bullet('Mechanism: Laser energy absorbed by haemoglobin/water → steam bubbles → thermal injury to vein wall → fibrosis')
add_bullet('Steps: USG-guided percutaneous access below knee → catheter to SFJ → TUMESCENT ANAESTHESIA → laser fired as catheter pulled back 3-7 mm/s → vein obliteration')
add_bullet('Closure rate: 90-95% at 3 years')
add_bullet('Complications: bruising, skin burns (prevented by tumescent), saphenous nerve injury (avoid below-knee), DVT, EHIT')
doc.add_paragraph()

add_para('2. RADIOFREQUENCY ABLATION (RFA / VNUS ClosureFast):', bold=True, color=(0x1F,0x4E,0x79))
add_bullet('Introduced: 2003; ClosureFast system (Medtronic) with 7-cm or 3-cm thermal tip')
add_bullet('Mechanism: Radiofrequency energy → resistive heating to 120°C → segmental vein wall closure')
add_bullet('Treatment: sequential 20-second cycles; catheter pulled back 6.5 cm per segment')
add_bullet('Access: percutaneous USG-guided below popliteal fossa for GSV; mid/lower calf for SSV')
add_bullet('Advantage over EVLA: less post-op bruising; comparable closure rates')
add_bullet('Tumescent anaesthesia essential: large-volume dilute lignocaine 0.1% + adrenaline perivenously — compresses vein + heat sink + analgesia')
add_bullet('Source: Current Surgical Therapy 14th Ed., p. 1237')
doc.add_paragraph()

add_para('3. NON-THERMAL NON-TUMESCENT (NTNT) Techniques — Recent Advances:', bold=True, color=(0x1F,0x4E,0x79))
add_table(
    ['Technique', 'Mechanism', 'Advantage'],
    [
        ['MOCA / ClariVein', 'Rotating wire abrades endothelium + simultaneous sclerosant injection', 'No tumescent; no thermal nerve injury; office procedure; ideal for tortuous veins'],
        ['VenaSeal (Cyanoacrylate glue)', 'Medical glue injected to seal vein lumen', 'No tumescent; no thermal; no post-op compression required; single session; high closure rates'],
        ['Varithena (Polidocanol microfoam)', 'FDA-approved standardised endovenous foam', 'Controlled foam volume; percutaneous; useful for larger veins'],
    ]
)
doc.add_paragraph()

add_heading('C. Sclerotherapy', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Type', 'Agent', 'Indication', 'Notes'],
    [
        ['Liquid sclerotherapy', 'Sodium tetradecyl sulphate (STD 0.5-3%) or polidocanol', 'Telangiectasias; small reticular veins', 'Injection → endothelial damage → sclerosis; compression 2-4 weeks post'],
        ['Foam sclerotherapy (Tessari method)', 'Liquid + air/CO₂ (1:4 ratio) → foam', 'Larger tributaries; accessory saphenous veins', 'Better wall contact than liquid; more effective for larger veins'],
        ['Ultrasound-Guided Foam Sclerotherapy (UGFS)', 'Foam under duplex guidance', 'Truncal GSV/SSV not suitable for thermal; recurrent varicosities', 'NICE 2013: second-line after endovenous thermal'],
        ['Microsclerotherapy', 'Very fine needle; dilute sclerosant', 'Telangiectasias (spider veins)', 'Cosmetic treatment'],
    ]
)
add_bullet('Complications of sclerotherapy: hyperpigmentation (most common), telangiectatic matting, DVT, visual disturbances, anaphylaxis (rare)')
doc.add_paragraph()

add_heading('D. Surgical Treatment', level=2, color=(0x2E,0x75,0xB6))
add_para('Indications for Surgery: Symptoms not controlled by conservative measures; complications (thrombophlebitis, haemorrhage, CEAP C4-C6); failed endovenous; patient preference; NICE 2013: surgery ONLY if endovenous and foam unsuitable.', bold=True)
doc.add_paragraph()
add_para('Trendelenburg Operation (Ligation of SFJ + Stripping):', bold=True, color=(0x1F,0x4E,0x79))
add_table(
    ['Step', 'Detail'],
    [
        ['1. FLUSH LIGATION of GSV at SFJ', '2 cm skin crease groin incision; divide ALL 5 tributaries at SFJ; flush ligation within 1 cm of common femoral vein wall — AVOIDS NEOVASCULARISATION and stump recurrence'],
        ['2. STRIPPING of GSV', 'From groin to UPPER CALF ONLY (NOT below knee — avoids saphenous nerve injury). PIN (Perforate Invaginate) stripping preferred — invaginates vein; less tissue trauma; less haematoma'],
        ['3. MULTIPLE AVULSIONS (Stab phlebectomy)', 'Residual tributary varicosities avulsed through 2-3 mm stab incisions using Müller hook; also called Ambulatory Phlebectomy'],
        ['4. SPJ LIGATION (if SSV incompetent)', 'Posterior popliteal incision; level confirmed by preoperative duplex; flush ligation of SSV at popliteal vein junction'],
    ]
)
doc.add_paragraph()
add_para('Emergency: Haemorrhage from ruptured varicose vein:', bold=True, color=(0xC0,0x00,0x00))
add_bullet('FIRST AID: Elevate limb + direct firm pressure — bleeding stops rapidly (unlike arterial bleeding)')
add_bullet('DO NOT apply tourniquet (impedes venous return → worsens bleeding)')
add_bullet('Definitive: treat varicose veins electively after haemostasis')
doc.add_paragraph()

add_heading('E. Management of Venous Leg Ulcer (CEAP C6)', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Step', 'Detail'],
    [
        ['1. Assessment', 'ABPI must be >0.8 before compression; duplex to confirm venous incompetence; wound swab if infected'],
        ['2. Compression (MAINSTAY)', '4-layer bandage (Charing Cross protocol) / multilayer compression; achieves ulcer healing in 70-80% at 12 weeks'],
        ['3. Wound care', 'Non-adherent dressings (Mepitel); debridement of slough; treat infection with systemic antibiotics'],
        ['4. Superficial venous ablation', 'After ulcer healed (C5) → ablate GSV to prevent recurrence. ESCHAR trial: early ablation alone does not heal ulcer faster but SIGNIFICANTLY REDUCES RECURRENCE'],
        ['5. Skin grafting', 'Pinch graft / split-thickness graft for large ulcers not responding to 12 weeks compression'],
        ['6. SEPS (Subfascial Endoscopic Perforator Surgery)', 'Endoscopic division of incompetent Cockett perforators via 2 ports; now largely replaced by endovenous perforator ablation'],
    ]
)
doc.add_paragraph()

# ═══ SECTION 7: COMPLICATIONS ═══
add_heading('7. COMPLICATIONS OF VARICOSE VEINS', level=1)
add_table(
    ['Complication', 'Notes'],
    [
        ['1. HAEMORRHAGE', 'Spontaneous rupture of thin-walled varix (skin very thin); often at night; FIRST AID = elevate + pressure'],
        ['2. SUPERFICIAL THROMBOPHLEBITIS', 'Painful, red, indurated cord over varix; manage with NSAIDs + compression + ambulation; anticoagulation if propagation within 3 cm of SFJ'],
        ['3. VARICOSE ECZEMA', 'Stasis dermatitis; itching, weeping, crusting; treat with topical steroids + emollients + compression'],
        ['4. LIPODERMATOSCLEROSIS', 'Fibrotic induration of skin + subcutaneous tissue; "champagne bottle leg"; precursor to ulceration'],
        ['5. ATROPHIE BLANCHE', 'White stellate scars at medial malleolus; painful; high risk of ulceration'],
        ['6. VENOUS (GRAVITATIONAL) ULCER', 'Most serious complication; medial gaiter area; chronic and recurrent; accounts for 2/3 of all leg ulcers'],
        ['7. HYPERPIGMENTATION', 'Haemosiderin deposition; brown discolouration at gaiter area'],
        ['8. PHLEBOLITHS', 'Calcification within thrombosed varicosity; visible on plain X-ray'],
        ['9. DVT / Pulmonary Embolism', 'Extension of superficial thrombophlebitis into deep system; rare but serious'],
    ]
)
doc.add_paragraph()

# ═══ SECTION 8: RECENT ADVANCES ═══
add_heading('8. RECENT ADVANCES', level=1)
ra = [
    'VenaSeal (cyanoacrylate glue) — no tumescent, no compression post-op, single session; rapidly expanding use',
    'ClariVein (MOCA) — mechano-chemical ablation; office procedure; ideal for tortuous veins',
    'Varithena (polidocanol endovenous microfoam) — FDA-approved, standardised, percutaneous',
    'Completely office-based duplex-guided endovenous approach under local anaesthesia',
    'May-Thurner syndrome management — iliac vein stenting for left-sided secondary varicosities',
    'Pelvic venous insufficiency treatment — embolisation of ovarian/pelvic veins for perineal varicosities',
    'NICE 2013 (CG168) — first-line = endovenous (EVLA/RFA); foam = second-line; surgery = third-line',
    'ERAS (Enhanced Recovery After Surgery) for day-case phlebectomy',
    'Wearable compression devices (Velcro-adjustable) for improved compliance in venous ulcer management',
]
for r in ra:
    add_bullet(r)
doc.add_paragraph()

# ═══ SCORING GUIDE ═══
add_heading("9. EXAMINER'S SCORING GUIDE — 30 Marks", level=1)
add_table(
    ['Section', 'Expected Marks'],
    [
        ['Anatomy of veins (deep + superficial + perforators + valves)', '8'],
        ['Diagram: venous system of lower limb (GSV, SSV, SFJ, SPJ, perforators)', '3'],
        ['Etiopathogenesis (types + risk factors + pathophysiology + theories)', '4'],
        ['Clinical features + clinical tests (Trendelenburg, Perthe, Morrissey)', '4'],
        ['Investigations + CEAP classification 2020 (full table)', '4'],
        ['Management (conservative + endovenous + sclerotherapy + surgical)', '5'],
        ['Complications + venous ulcer management', '2'],
        ['TOTAL', '30'],
    ]
)
doc.add_paragraph()

add_heading("Mark-Winning Sharp-Edge Discriminators", level=2, color=(0x2E,0x75,0xB6))
tips = [
    'GSV termination: 3.5 cm BELOW AND LATERAL to the pubic tubercle (not medial)',
    'Saphenous NERVE runs with GSV in the leg — medial calf paraesthesia if injured (avoid stripping below knee)',
    "PERTHE'S TEST: tests DEEP VEIN PATENCY — positive (veins increase on walking) = CONTRAINDICATION to surgery",
    "CEAP 2020 additions: C2r (recurrent varicose veins), C4c (corona phlebetatica), C6r (recurrent ulcer)",
    "NICE 2013 (CG168): EVLA/RFA = first-line; foam sclerotherapy = second; surgery = third-line ONLY if neither suitable",
    "CARLOS BONÉ (1999) = first EVLA; ClosureFast (2003) = RFA system",
    "Fibrin Cuff Theory = Browse & Burnand; White Cell Trapping Theory — both explain ulcer pathogenesis",
    "COCKETT'S perforators at 6, 13.5, 18 cm above medial malleolus → incompetence → medial gaiter ulcers",
    "SAPHENA VARIX: fluctuant groin swelling at SFJ — transmits cough impulse; distinguish from femoral hernia",
    "Haemorrhage from varicosity: elevate + press (NOT tourniquet — worsens by obstructing venous return)",
    "Ambulatory Venous Pressure (AVP): falls to 20-25 mmHg on exercise normally; does NOT fall in venous insufficiency",
    "Giacomini vein (connects SSV to GSV) — source of recurrent varicosities if missed",
]
for t in tips:
    add_bullet(t)
doc.add_paragraph()

p_src = doc.add_paragraph()
run_src = p_src.add_run("Sources: Sabiston Textbook of Surgery 21st Ed. (p. 2399-2412) | Mulholland & Greenfield's Surgery 7th Ed. (p. 5216-5229) | Current Surgical Therapy 14th Ed. (p. 1235-1240)")
run_src.italic = True; run_src.font.size = Pt(9)
run_src.font.color.rgb = RGBColor(0x70, 0x70, 0x70)

out_path = '/tmp/workspace/ms-surgery-notes/Varicose_Veins_30marks.docx'
doc.save(out_path)
print(f'Saved: {out_path}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()
section = doc.sections[0]
section.top_margin = Cm(2); section.bottom_margin = Cm(2)
section.left_margin = Cm(2.5); section.right_margin = Cm(2.5)
doc.styles['Normal'].font.name = 'Arial'
doc.styles['Normal'].font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def add_heading(text, level=1, color=(0x1F, 0x4E, 0x79)):
    p = doc.add_heading(text, level=level)
    for run in p.runs:
        run.font.color.rgb = RGBColor(*color)
    return p

def add_para(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    run = p.add_run(text)
    run.bold = bold; run.italic = italic; run.font.size = Pt(size)
    if color:
        run.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def add_bullet(text, bold=False):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    r = p.add_run(text)
    r.font.size = Pt(11)
    r.bold = bold
    return p

def set_cell_bg(cell, hex_color):
    tc = cell._tc; tcPr = tc.get_or_add_tcPr()
    shd = OxmlElement('w:shd')
    shd.set(qn('w:val'), 'clear'); shd.set(qn('w:color'), 'auto')
    shd.set(qn('w:fill'), hex_color); tcPr.append(shd)

def add_table(headers, rows, hdr_color='1F4E79', alt_row_color='D6E4F0'):
    table = doc.add_table(rows=1+len(rows), cols=len(headers))
    table.style = 'Table Grid'
    hdr = table.rows[0].cells
    for i, h in enumerate(headers):
        hdr[i].text = h
        set_cell_bg(hdr[i], hdr_color)
        for para in hdr[i].paragraphs:
            for run in para.runs:
                run.bold = True; run.font.size = Pt(10)
                run.font.color.rgb = RGBColor(0xFF, 0xFF, 0xFF)
    for ri, row_data in enumerate(rows):
        cells = table.rows[ri+1].cells
        for ci, txt in enumerate(row_data):
            cells[ci].text = txt
            for para in cells[ci].paragraphs:
                for run in para.runs:
                    run.font.size = Pt(10)
        if ri % 2 == 0:
            for cell in cells:
                set_cell_bg(cell, alt_row_color)
    return table

def embed_image(url, path, width=Inches(5.0), caption=None):
    try:
        r = requests.get(url, timeout=15)
        if r.status_code == 200:
            with open(path, 'wb') as f: f.write(r.content)
            doc.add_picture(path, width=width)
            doc.paragraphs[-1].alignment = WD_ALIGN_PARAGRAPH.CENTER
            if caption:
                cap = doc.add_paragraph(caption)
                cap.alignment = WD_ALIGN_PARAGRAPH.CENTER
                cap.runs[0].italic = True
                cap.runs[0].font.size = Pt(9)
    except Exception as e:
        add_para(f'[Image: {caption}]', italic=True, color=(0x70,0x70,0x70))

# ══ COVER ══
p = doc.add_paragraph(); p.alignment = WD_ALIGN_PARAGRAPH.CENTER
run = p.add_run('MS GENERAL SURGERY — EXAM NOTES')
run.bold = True; run.font.size = Pt(18); run.font.color.rgb = RGBColor(0x1F, 0x4E, 0x79)

p2 = doc.add_paragraph(); p2.alignment = WD_ALIGN_PARAGRAPH.CENTER
run2 = p2.add_run('Spleen — Anatomy, Hypersplenism & Splenectomy — 30-Mark Question')
run2.bold = True; run2.font.size = Pt(14); run2.font.color.rgb = RGBColor(0x2E, 0x75, 0xB6)

p3 = doc.add_paragraph(); p3.alignment = WD_ALIGN_PARAGRAPH.CENTER
run3 = p3.add_run("Sources: Current Surgical Therapy 14th Ed. | Sabiston 21st Ed. | Bailey & Love 28th Ed.")
run3.italic = True; run3.font.size = Pt(10); run3.font.color.rgb = RGBColor(0x70, 0x70, 0x70)
doc.add_paragraph()

pq = doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Describe surgical anatomy of the spleen. Discuss causes, clinical features, investigations and management of Hypersplenism. Write a short note on splenectomy — indications, technique, complications and post-splenectomy care."   [30 Marks]').bold = True
pq.runs[0].font.size = Pt(11); pq.runs[0].font.color.rgb = RGBColor(0x7B, 0x22, 0x00)
doc.add_paragraph()

embed_image(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_a59455077c66bb83886b491604b7cbde96bc54bc230f8b2d598e42a7d80c90bf.jpg',
    '/tmp/workspace/ms-surgery-notes/spleen_artery.jpg',
    width=Inches(4.5),
    caption='Figure: Splenic artery branching (Superior + Inferior branch) at the splenic hilum. Splenic vein runs inferior to artery. Tail of pancreas lies in splenorenal ligament. (Surgical Anatomy — Current Surgical Therapy 14th Ed.)'
)
doc.add_paragraph()

# ══ SECTION 1: ANATOMY ══
add_heading('1. SURGICAL ANATOMY OF THE SPLEEN', level=1)
add_para('EXAM TIP: Draw a diagram showing the spleen in situ with its 4 peritoneal ligaments and hilar relations — 3-4 marks.', bold=True, color=(0xC0,0x00,0x00))

add_heading('A. Position, Size and Weight', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Feature', 'Detail'],
    [
        ['Position', 'Upper LEFT quadrant; hypochondrium; posterior to the stomach'],
        ['Protected by', 'Ribs 9 to 12 (left side) — makes palpation difficult until 2-3x enlarged'],
        ['Long axis', 'Lies obliquely along the 10th rib'],
        ['Normal dimensions', 'Length: 10-12 cm; Width: 7 cm; Thickness: 3-4 cm'],
        ['Normal weight', '100-150 g'],
        ['Peritoneum', 'Completely invested by visceral peritoneum EXCEPT at the hilum'],
    ]
)
doc.add_paragraph()
add_para('Source: Current Surgical Therapy 14th Ed., p. 698', italic=True, color=(0x70,0x70,0x70), size=9)
doc.add_paragraph()

add_heading('B. Peritoneal Ligaments — HIGH YIELD (4 Ligaments)', level=2, color=(0x2E,0x75,0xB6))
add_para('Mnemonic: "Go Sit Properly Sober" — Gastrosplenic, Splenorenal, Phrenicosplenic, Splenocolic', bold=True, color=(0x1F,0x4E,0x79))
add_table(
    ['Ligament', 'Connects To', 'Contains', 'Surgical Importance'],
    [
        ['GASTROSPLENIC\n(Gastrolienal)', 'Greater curvature of stomach', 'SHORT GASTRIC VESSELS (3-7)\n+ Left gastroepiploic vessels', 'Must divide for hilum access; CONTAINS VESSELS — ligate carefully; risk of gastric perforation if torn'],
        ['SPLENORENAL\n(Lienorenal)', 'Left kidney / posterior abdominal wall', 'SPLENIC VESSELS (artery + vein)\n+ TAIL OF PANCREAS', 'HIGHEST RISK ligament — tail of pancreas within → injury → pancreatitis, fistula, pseudocyst'],
        ['PHRENICOSPLENIC\n(Phrenicocolic)', 'Diaphragm superiorly + splenic flexure', 'Usually AVASCULAR', 'Safe to divide; supports superolateral surface; divide to mobilise superior pole'],
        ['SPLENOCOLIC', 'Splenic flexure of colon (inferior)', 'Inferior polar vessels', 'FIRST LIGAMENT divided at laparoscopic splenectomy; inferior pole mobilisation'],
    ]
)
doc.add_paragraph()

add_heading('C. Relations', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Surface', 'Relation'],
    [
        ['Diaphragmatic (convex) surface', 'Left dome of diaphragm; left pleural cavity (ribs 9-12) above'],
        ['Gastric surface (visceral)', 'Stomach anteriorly via gastrosplenic ligament'],
        ['Renal surface (visceral)', 'Left kidney + left adrenal gland'],
        ['Colic surface (visceral)', 'Splenic flexure of colon'],
        ['Pancreatic surface', 'Tail of pancreas at the hilum'],
    ]
)
doc.add_paragraph()

add_heading('D. Blood Supply', level=2, color=(0x2E,0x75,0xB6))
add_para('Splenic Artery:', bold=True)
add_bullet('Origin: COELIAC AXIS (in majority); rarely from aorta, SMA, left gastric, left hepatic artery')
add_bullet('Course: Tortuous, runs along UPPER BORDER OF PANCREAS in retroperitoneum')
add_para('Two branching patterns (Current Surgical Therapy):', bold=True, color=(0x1F,0x4E,0x79))
add_table(
    ['Type', 'Description', 'Surgical Implication'],
    [
        ['DISTRIBUTED (majority)', 'Artery branches early → multiple small vessels enter hilum over a WIDE AREA', 'Segmental blood supply → partial splenectomy possible'],
        ['MAGISTRAL (minority)', 'Long main trunk → divides CLOSE TO HILUM into 3-4 large compact branches', 'Difficult individual vessel dissection; higher bleeding risk'],
    ]
)
doc.add_paragraph()
add_bullet('Branches: Short gastric arteries (5-7), left gastroepiploic artery, inferior polar artery, superior polar artery')
add_bullet('Splenic artery is END-ARTERY at segmental level → segmental infarcts occur with embolisation')
add_bullet('EARLY LIGATION of splenic artery on the superior pancreatic border = KEY SURGICAL MANOEUVRE → reduces spleen size + autotransfuses 200-300 mL blood')
doc.add_paragraph()
add_para('Splenic Vein:', bold=True)
add_bullet('Formed at hilum; runs INFERIOR and POSTERIOR to splenic artery')
add_bullet('Receives: short gastric veins, left gastroepiploic vein, inferior mesenteric vein')
add_bullet('Joins with superior mesenteric vein behind neck of pancreas → PORTAL VEIN')
doc.add_paragraph()

add_heading('E. Accessory Spleens (Spleniculi)', level=2, color=(0x2E,0x75,0xB6))
add_bullet('Present in 15-30% of population')
add_table(
    ['Location', 'Frequency'],
    [
        ['SPLENIC HILUM', '50% (most common)'],
        ['Gastrosplenic ligament', '25%'],
        ['Tail of pancreas', '6%'],
        ['Greater omentum', '4%'],
        ['Left gonadal region / mesentery / pelvis', 'Remainder'],
    ]
)
doc.add_paragraph()
add_bullet('SURGICAL IMPORTANCE: Must be identified and removed at splenectomy for haematological diseases (ITP, HS) — if missed, disease RECURS due to residual splenic tissue', bold=True)
doc.add_paragraph()

add_heading('F. Microstructure', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Component', 'Structure', 'Function'],
    [
        ['Capsule', 'Dense fibrous + smooth muscle; sends trabeculae into parenchyma', 'Support; contraction expels stored blood (reservoir)'],
        ['WHITE PULP', 'Periarteriolar lymphoid sheaths (PALS) around central arteries + B-cell follicles', 'Immunological: T-cells in PALS; B-cells in follicles; IgM production'],
        ['MARGINAL ZONE', 'Between red and white pulp', 'Trapping blood-borne antigens; antigen presentation; first-line immune response to encapsulated bacteria'],
        ['RED PULP', 'Venous sinuses + splenic cords of Billroth', 'Filtration of old/abnormal RBCs; haemopoiesis; blood reservoir; removes Howell-Jolly bodies, siderocytes, target cells'],
    ]
)
doc.add_paragraph()

# ══ SECTION 2: FUNCTIONS ══
add_heading('2. FUNCTIONS OF THE SPLEEN', level=1)
add_table(
    ['Function', 'Detail'],
    [
        ['1. FILTRATION (most important)', 'Phagocytosis of old, damaged, senescent RBCs + platelets + bacteria by splenic macrophages in red pulp cords. Removes Howell-Jolly bodies, siderocytes, target cells, opsonised bacteria'],
        ['2. IMMUNOLOGICAL', 'Production of opsonins — IgM (early antibody), PROPERDIN (Factor P — complement activation), TUFTSIN (Thr-Lys-Pro-Arg — tetrapeptide stimulating phagocytosis). T+B lymphocyte activation vs encapsulated bacteria'],
        ['3. HAEMATOPOIESIS', 'Extramedullary haematopoiesis in FOETAL LIFE (until 5th month). Resumes in adult life in myeloproliferative disorders (myelofibrosis, CML)'],
        ['4. RESERVOIR', 'Stores up to 300 mL blood; releases on sympathetic stimulation (exercise, haemorrhage, stress)'],
        ['5. PLATELET STORAGE', '~30% of total platelet mass stored in spleen at any given time'],
        ['6. IRON RECYCLING', 'Haemoglobin broken down in red pulp → iron recycled to bone marrow via transferrin'],
        ['7. OPSONIN PRODUCTION', 'Tuftsin: Thr-Lys-Pro-Arg produced ONLY by spleen → stimulates phagocytosis. Absent post-splenectomy → OPSI risk'],
    ]
)
doc.add_paragraph()

# ══ SECTION 3: SPLENOMEGALY ══
add_heading('3. SPLENOMEGALY', level=1)
add_para('Definition: Palpable spleen OR spleen length >13 cm on ultrasound. Massive splenomegaly = spleen reaching or crossing the umbilicus.', bold=True)
add_para('Most common cause worldwide = Visceral leishmaniasis (Kala-azar). Most common surgical cause = Portal hypertension (cirrhosis).', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()
add_heading('Causes of Splenomegaly', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Category', 'Examples'],
    [
        ['INFECTIVE', 'Malaria (commonest worldwide), Visceral leishmaniasis/Kala-azar (massive), Infectious mononucleosis (EBV), Typhoid, Brucellosis, SBE, HIV, TB, CMV'],
        ['HAEMATOLOGICAL', 'Hereditary spherocytosis, Thalassaemia major, Sickle cell disease (early; later auto-splenectomy), CML (massive), AML, CLL, Lymphoma (Hodgkin + NHL), ITP, AIHA, Myelofibrosis'],
        ['CONGESTIVE\n(Portal hypertension)', 'Liver cirrhosis (most common in India/surgical setting), Budd-Chiari syndrome, Portal vein thrombosis, Splenic vein thrombosis, Right heart failure, Constrictive pericarditis'],
        ['INFILTRATIVE /\nSTORAGE DISORDERS', 'Gaucher\'s disease (most common storage disorder), Niemann-Pick disease, Amyloidosis, Haemochromatosis, Sarcoidosis'],
        ['AUTOIMMUNE', "SLE, FELTY'S SYNDROME (RA + splenomegaly + neutropenia — triad), Sjögren's syndrome"],
        ['NEOPLASTIC (primary)', 'Splenic haemangioma (most common benign tumour), Lymphoma, Angiosarcoma (rare but malignant)'],
        ['CYSTIC', 'Hydatid cyst (Echinococcus granulosus), Post-traumatic pseudocyst, Congenital (epidermoid) cyst'],
        ['MISCELLANEOUS', 'Idiopathic, Splenic artery aneurysm, Polycythaemia vera'],
    ]
)
doc.add_paragraph()

# ══ SECTION 4: HYPERSPLENISM ══
add_heading('4. HYPERSPLENISM', level=1)
add_para("DEFINITION (Dameshek's Criteria, 1955) — ALL FOUR must be present:", bold=True, color=(0xC0,0x00,0x00))
add_table(
    ['Criterion', 'Detail'],
    [
        ['1. SPLENOMEGALY', 'Palpably or radiologically enlarged spleen'],
        ['2. CYTOPENIA', 'Anaemia, leukopenia, thrombocytopenia — one or more cell lines reduced in peripheral blood'],
        ['3. NORMAL / HYPERPLASTIC BONE MARROW', 'Compensatory increased marrow activity (to counteract peripheral destruction) — biopsy essential'],
        ['4. CORRECTION BY SPLENECTOMY', 'Cytopenia corrects after splenectomy — retrospective criterion'],
    ]
)
doc.add_paragraph()
add_para('Primary hypersplenism: No identifiable underlying disease', bold=False)
add_para('Secondary hypersplenism: Due to identifiable cause (portal hypertension, storage disorder, haematological malignancy)', bold=False)
doc.add_paragraph()
add_heading('Mechanism of Cytopenia', level=2, color=(0x2E,0x75,0xB6))
steps_hyper = [
    'Enlarged spleen (from any cause) → increased blood volume sequestered',
    'Up to 90% of platelets, 45% of RBCs can be sequestered within the enlarged spleen',
    'Excess pooling → prolonged exposure → increased macrophage-mediated destruction',
    'Peripheral cytopenia → bone marrow compensates (hyperplasia)',
    'Despite marrow compensation, net peripheral cell loss continues → symptomatic cytopenia',
]
for s in steps_hyper:
    add_bullet(s)
doc.add_paragraph()

# ══ SECTION 5: CLINICAL FEATURES ══
add_heading('5. CLINICAL FEATURES', level=1)
add_heading('Symptoms', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Symptom', 'Notes'],
    [
        ['Abdominal fullness / LUQ discomfort', 'From mass effect of massive splenomegaly'],
        ['Early satiety', 'Gastric compression by enlarged spleen'],
        ["Kehr's sign", 'Left shoulder tip pain — diaphragmatic irritation (classic in splenic rupture / infarct)'],
        ['Fatigue, pallor, dyspnoea', 'From anaemia (cytopenia)'],
        ['Bleeding tendency', 'Petechiae, purpura, gum bleeding — thrombocytopenia'],
        ['Recurrent infections', 'Leukopenia + impaired opsonins'],
        ['Symptoms of underlying cause', 'Fever (infection/malaria), Jaundice (haemolysis), Portal hypertension features (haematemesis, ascites)'],
    ]
)
doc.add_paragraph()
add_heading('Signs', level=2, color=(0x2E,0x75,0xB6))
add_para('Distinguishing splenomegaly from left kidney enlargement (EXAM CLASSIC):', bold=True, color=(0x1F,0x4E,0x79))
add_table(
    ['Feature', 'Splenomegaly', 'Enlarged Left Kidney'],
    [
        ['Moves with respiration', 'YES', 'Less so'],
        ['Can get above the swelling', 'NO', 'YES (can insinuate fingers above kidney)'],
        ['Medial notch', 'YES (splenic notch)', 'NO'],
        ['Percussion', 'DULL (no bowel in front)', 'Resonant (bowel in front)'],
        ['Bimanual ballotability', 'NOT ballotable', 'BALLOTABLE (retroperitoneal)'],
        ['Direction of enlargement', 'Towards right iliac fossa (obliquely along 10th rib)', 'Downward only'],
    ]
)
doc.add_paragraph()

# ══ SECTION 6: INVESTIGATIONS ══
add_heading('6. INVESTIGATIONS', level=1)
add_table(
    ['Investigation', 'Purpose / Detail'],
    [
        ['FBC (Full Blood Count)', 'Confirms cytopenia — anaemia, leukopenia, thrombocytopenia; baseline for monitoring'],
        ['Peripheral Blood Smear', 'Spherocytes (HS); target cells (thalassaemia); blast cells (leukaemia); Howell-Jolly bodies (asplenia); malarial parasites'],
        ['BONE MARROW ASPIRATION + BIOPSY', 'ESSENTIAL for Dameshek criterion 3 — hyperplastic marrow = hypersplenism; infiltration = leukaemia/lymphoma/myelofibrosis'],
        ['LFTs, serum albumin', 'Portal hypertension / cirrhosis assessment'],
        ['ULTRASOUND ABDOMEN (first-line imaging)', 'Confirms splenomegaly; measures dimensions; portal vein diameter + flow; hepatic disease; splenic cysts; vein thrombosis'],
        ['CT ABDOMEN (contrast) — best for pre-op planning', 'Detailed anatomy; splenic vessel assessment; tumours; abscesses; trauma grading (AAST); accessory spleens'],
        ['Coombs test (DCT)', 'Autoimmune haemolytic anaemia (warm antibody type)'],
        ['Osmotic Fragility Test', 'Hereditary spherocytosis — increased fragility'],
        ['Hb Electrophoresis', 'Thalassaemia, sickle cell disease'],
        ['Malaria film / RDT, Leishmania serology (rK39)', 'Infective causes'],
        ['Isotope scan (Tc-99m sulphur colloid)', 'Identifies accessory spleens; confirms splenic tissue (esp. post-splenectomy recurrence)'],
        ['PET-CT', 'Lymphoma staging'],
    ]
)
doc.add_paragraph()

# ══ SECTION 7: MANAGEMENT ══
add_heading('7. MANAGEMENT', level=1)
add_heading('Conservative', level=2, color=(0x2E,0x75,0xB6))
add_bullet('Treat underlying cause (anti-malarials, antibiotics, immunosuppression)')
add_bullet('Haematological support: transfusions for severe anaemia; platelet transfusion for active bleeding')
add_bullet('Steroids (prednisolone 1 mg/kg/day) for AIHA + ITP — first-line before splenectomy')
add_bullet('IVIG for ITP — raises platelets rapidly pre-operatively')
doc.add_paragraph()

# ══ SECTION 8: SPLENECTOMY ══
add_heading('8. SPLENECTOMY', level=1)
add_heading('Indications', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Category', 'Specific Conditions'],
    [
        ['HAEMATOLOGICAL\n(most common elective indication)', 'ITP — after failure of steroids + IVIG for >6 months; HEREDITARY SPHEROCYTOSIS — definitive cure; Autoimmune haemolytic anaemia (warm type); Thalassaemia major (massive splenomegaly + transfusion dependence); Hereditary elliptocytosis; Myelofibrosis; Felty\'s syndrome (RA + splenomegaly + neutropenia)'],
        ['TRAUMA', 'Splenic laceration/rupture — haemodynamically unstable OR NOM failure; Grade IV-V AAST injuries'],
        ['HYPERSPLENISM', 'Portal hypertension with massive splenomegaly + symptomatic cytopenia; Gaucher\'s disease'],
        ['SPLENIC TUMOURS', 'Lymphoma (staging/therapeutic); Haemangioma >2 cm; Angiosarcoma; Metastases'],
        ['SPLENIC CYSTS', 'Large/symptomatic; parasitic (hydatid — careful to avoid rupture/anaphylaxis); post-traumatic pseudocysts'],
        ['SPLENIC ABSCESS', 'Multiloculated or failed percutaneous drainage'],
        ['INCIDENTAL / IATROGENIC', 'Accidental injury during gastrectomy, pancreatectomy, left colectomy'],
        ['DIAGNOSTIC', 'Unexplained splenomegaly when biopsy not possible/non-diagnostic'],
    ]
)
doc.add_paragraph()

add_heading('Preoperative Preparation — CRITICAL', level=2, color=(0x2E,0x75,0xB6))
add_para('VACCINATION is the single most important preoperative step — give 2 weeks BEFORE elective splenectomy:', bold=True, color=(0xC0,0x00,0x00))
add_table(
    ['Preparation', 'Detail'],
    [
        ['PNEUMOCOCCAL VACCINE\n(Most important)', 'Pneumovax 23 (polyvalent polysaccharide) OR PCV13/PCV20 (conjugate — preferred as better T-cell response). Target: S. pneumoniae — causes 50% of OPSI. Give 2 weeks BEFORE elective surgery; 2 weeks AFTER emergency splenectomy'],
        ['HIB VACCINE', 'Haemophilus influenzae type b conjugate vaccine — second most important'],
        ['MENINGOCOCCAL VACCINE', 'MenACWY + MenB — complete series. Protects against N. meningitidis'],
        ['Platelet transfusion (ITP)', 'Give INTRAOPERATIVELY just before skin incision — NOT pre-operatively (destroyed by same autoantibody mechanism)'],
        ['Steroids', 'ITP patients on steroids: continue peri-operatively; stress dose if on long-term steroids'],
        ['Cross-match blood', '2-4 units packed RBCs (esp. if portal hypertension)'],
        ['DVT prophylaxis', 'Post-splenectomy thrombocytosis → thrombotic risk; LMWH + TED stockings'],
    ]
)
doc.add_paragraph()

add_heading('Operative Technique — Open Splenectomy', level=2, color=(0x2E,0x75,0xB6))
add_para('Position: Supine or right lateral decubitus with roll under left flank.', bold=False)
add_para('Incision: Midline laparotomy (emergency/trauma) OR left subcostal (Kocher) incision (elective).', bold=False)
doc.add_paragraph()
steps = [
    '1. Enter lesser sac through gastrocolic omentum to access splenic hilum',
    '2. Divide splenocolic ligament (inferior, usually avascular) — mobilises lower pole',
    '3. Divide gastrosplenic ligament — carefully ligate short gastric vessels (3-7) close to stomach wall',
    '4. EARLY LIGATION OF SPLENIC ARTERY on upper border of pancreas (distal to left gastroepiploic origin) — KEY STEP: reduces spleen size, autotransfuses 200-300 mL blood, reduces bleeding',
    '5. Identify and protect TAIL OF PANCREAS within splenorenal ligament',
    '6. Divide splenorenal ligament — ligate splenic vein individually close to hilum',
    '7. Ligate splenic artery and vein individually at hilum (or use stapler); take hilar vessels individually to avoid pancreatic tail injury',
    '8. SEARCH FOR ACCESSORY SPLEENS — hilum (50%), gastrosplenic ligament, omentum, gonadal region, mesentery, pelvis — ALL MUST BE REMOVED in haematological disease',
    '9. Haemostasis; drain placement optional (place if pancreatic injury suspected)',
]
for s in steps:
    add_bullet(s)
doc.add_paragraph()

add_heading('Laparoscopic Splenectomy (preferred for elective, normal or moderately enlarged spleen)', level=2, color=(0x2E,0x75,0xB6))
add_bullet('INTRODUCED: 1991 by DELAITRE — sharp-edge discriminator', bold=True)
add_bullet('Position: Right lateral decubitus — uses gravity as natural retractor')
add_bullet('Ports: 4 ports (one 10-12 mm + three 5 mm); left flank and epigastric region')
add_para('Sequence of steps (Current Surgical Therapy 14th Ed., p. 700):', bold=True, color=(0x1F,0x4E,0x79))
lap_steps = [
    '1. Splenocolic ligament divided FIRST (vessel-sealing device) — inferior pole mobilisation',
    '2. Gastrosplenic ligament divided — short gastric vessels ligated (vessel-sealing device)',
    '3. Superior pole mobilised by dividing highest part of splenorenal ligament toward left crus',
    '4. Tail of pancreas identified in relation to splenic hilum',
    '5. Hilum: endoscopic stapler (vascular cartridge) — single or serial firings across hilum',
    '6. Search for accessory spleens throughout (folded between stomach and liver for retrieval)',
    '7. Spleen placed in reinforced plastic retrieval bag ("scorpion tail" technique); morcellated within bag; extracted through largest port site (extended if needed)',
]
for s in lap_steps:
    add_bullet(s)
doc.add_paragraph()
add_table(
    ['Approach', 'Advantage', 'Disadvantage'],
    [
        ['Standard laparoscopic', 'Less pain, shorter stay, fewer wound complications, faster recovery', 'Limited for massive spleens >20 cm'],
        ['Hand-assisted laparoscopic (HALS)', 'Manual control for massive spleens; reduced conversion rate', 'Larger incision (hand port)'],
        ['Robotic splenectomy', '3D HD vision; wristed instruments; precise dissection near hilum', 'Higher cost; longer setup time; limited availability'],
    ]
)
doc.add_paragraph()

add_heading('AAST Splenic Trauma Grading', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Grade', 'Description', 'Management'],
    [
        ['I', 'Subcapsular haematoma <10% surface area; laceration <1 cm deep', 'NOM — ICU monitoring'],
        ['II', 'Subcapsular haematoma 10-50%; laceration 1-3 cm', 'NOM if haemodynamically stable'],
        ['III', 'Subcapsular haematoma >50%; laceration >3 cm; ruptured subcapsular haematoma', 'NOM in stable patients; consider angioembolisation if "blush" on CT'],
        ['IV', 'Laceration involving segmental vessels; devascularisation >25%', 'Angioembolisation OR surgery (splenorrhaphy or splenectomy)'],
        ['V', 'Shattered spleen; hilar injury with complete devascularisation', 'EMERGENCY SPLENECTOMY'],
    ]
)
add_para('NOM success rates: Grade I-II >95%; Grade III 80%; Grade IV-V <50%', bold=True, color=(0x1F,0x4E,0x79))
doc.add_paragraph()

# ══ SECTION 9: COMPLICATIONS ══
add_heading('9. COMPLICATIONS OF SPLENECTOMY', level=1)
add_heading('Intraoperative', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Complication', 'Cause / Note'],
    [
        ['Haemorrhage', 'Hilar vessel injury; short gastric vessel avulsion; pancreatic tail injury'],
        ['Gastric injury', 'Thermal injury or division of short gastric vessels too close to stomach'],
        ['PANCREATIC TAIL INJURY', 'In splenorenal ligament → pancreatitis, pancreatic fistula, pseudocyst (most feared specific complication)'],
        ['Left colonic injury', 'Splenocolic ligament division — risk to splenic flexure'],
        ['Diaphragmatic injury', 'Division of phrenicosplenic ligament — risk of diaphragmatic tear'],
    ]
)
doc.add_paragraph()
add_heading('Early Post-operative', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Complication', 'Notes'],
    [
        ['Haemorrhage (secondary)', 'Slipped ligature; re-explore if drain output >250 mL/hour'],
        ['SUBPHRENIC ABSCESS', 'Left subphrenic collection; fever, left shoulder pain, elevated left hemidiaphragm on CXR; treat by percutaneous drainage'],
        ['Pancreatitis / Pancreatic fistula', 'Tail of pancreas injured → raised amylase in drain fluid; diagnose by drain amylase level'],
        ['Left lower lobe atelectasis', 'Left hemidiaphragm splinting + left pleural effusion; physiotherapy + incentive spirometry'],
        ['Portal/Splenic vein thrombosis', 'Esp. in myeloproliferative disorders (thrombocytosis + hypercoagulability); anticoagulate if confirmed'],
        ['REACTIVE THROMBOCYTOSIS', 'Platelet count rises to 600,000-1,000,000+ post-splenectomy; aspirin if moderate; anticoagulation if >1,000,000'],
    ]
)
doc.add_paragraph()

add_heading('LATE COMPLICATION — OPSI (MOST IMPORTANT)', level=2, color=(0xC0,0x00,0x00))
add_para('Overwhelming Post-Splenectomy Infection (OPSI) / Overwhelming Post-Splenectomy Sepsis (OPSS)', bold=True, color=(0xC0,0x00,0x00))
add_table(
    ['Feature', 'Detail'],
    [
        ['Risk period', 'LIFELONG; highest in FIRST 2 YEARS post-splenectomy'],
        ['Lifetime risk', '2-5% overall; higher in children <5 years + immunocompromised'],
        ['ORGANISMS\n(Encapsulated bacteria)', '1. Streptococcus pneumoniae — MOST COMMON (50%)\n2. Haemophilus influenzae type b\n3. Neisseria meningitidis\nAlso: Escherichia coli, Babesia microti (tick-borne), Malaria (Plasmodium)'],
        ['Pathogenesis', 'Loss of opsonins (IgM, properdin, tuftsin) + loss of marginal zone macrophages → cannot opsonise encapsulated bacteria → overwhelming bacteraemia → DIC → multi-organ failure'],
        ['Clinical course', 'RAPID: Prodrome (fever, rigors, headache, malaise) → rapid deterioration within HOURS → DIC → death within 12-24 HOURS'],
        ['MORTALITY', '50-70% once OPSI established — examiner favourite fact'],
    ]
)
doc.add_paragraph()
add_heading('Prevention of OPSI (POST-SPLENECTOMY CARE)', level=2, color=(0x2E,0x75,0xB6))
add_table(
    ['Measure', 'Detail'],
    [
        ['VACCINATION\n(Most important)', 'Pneumococcal + Hib + Meningococcal (MenACWY + MenB)\nElective: give 2 WEEKS BEFORE surgery\nEmergency: give 2 WEEKS AFTER surgery\nBooster: Pneumococcal every 5 years; others per schedule\nFlu vaccine: annually'],
        ['PROPHYLACTIC ANTIBIOTICS\n(Lifelong)', 'Oral PENICILLIN V (phenoxymethylpenicillin) 250 mg BD\nAlternative (penicillin-allergic): Erythromycin 250 mg BD or Co-trimoxazole\nDuration: Lifelong in children (some until age 16); minimum 2-5 years in adults; lifelong if high-risk'],
        ['PATIENT EDUCATION', 'Medical alert bracelet/card\nAny fever = SEEK IMMEDIATE MEDICAL ATTENTION (emergency department)\nStandby broad-spectrum antibiotics (amoxicillin-clavulanate) for travel / early fever\nNever ignore a febrile illness'],
        ['TRAVEL PRECAUTIONS', 'Malaria prophylaxis MANDATORY for endemic area travel\nAvoid tick bites (Babesia risk)\nFull vaccination record required for travel'],
    ]
)
doc.add_paragraph()

# ══ SECTION 10: SPECIAL CONDITIONS ══
add_heading('10. SPECIAL CONDITIONS', level=1)
add_heading('ITP (Immune Thrombocytopenic Purpura)', level=2, color=(0x2E,0x75,0xB6))
add_bullet('Mechanism: IgG auto-antibodies against platelet glycoproteins (GPIIb/IIIa, GPIb) → platelet destruction by splenic macrophages + splenic B-cells produce antibody')
add_bullet('Splenectomy role: Removes both the site of antibody PRODUCTION and DESTRUCTION')
add_bullet('Complete response: 65-70%; partial response: additional 20%')
add_bullet('Indication for splenectomy: Platelet <20,000 after 6 months of steroids + IVIG failure (chronic ITP)')
add_bullet('GIVE PLATELETS INTRAOPERATIVELY — just before skin incision (NOT preoperatively — they get destroyed)')
add_bullet('Vaccinate 2 weeks before surgery')
doc.add_paragraph()

add_heading('Hereditary Spherocytosis (HS)', level=2, color=(0x2E,0x75,0xB6))
add_bullet('Defect: Spectrin / Ankyrin / Band 3 / Protein 4.2 deficiency → RBCs lose biconcave shape → become spherical → trapped and destroyed in red pulp')
add_bullet('Splenectomy = DEFINITIVE CURATIVE TREATMENT (removes site of destruction)')
add_bullet('DELAY until age 5-6 (preserve childhood immune function; risk of OPSI highest in young children)')
add_bullet('ALL ACCESSORY SPLEENS MUST BE REMOVED — if missed, haemolytic anaemia RECURS')
add_bullet('Post-splenectomy: Spherocytes PERSIST in smear but are no longer destroyed → Hb normalises; Howell-Jolly bodies appear')
doc.add_paragraph()

# ══ SECTION 11: RECENT ADVANCES ══
add_heading('11. RECENT ADVANCES', level=1)
advances = [
    'PARTIAL SPLENECTOMY / SPLEEN-PRESERVING SURGERY — for benign cysts, haemangioma, Grade I-III trauma; preserves immune function',
    'SPLENIC ARTERY EMBOLISATION (SAE) — for trauma haemorrhage (active blush on CT); hypersplenism; splenic artery aneurysm',
    'ROBOTIC SPLENECTOMY — improved 3D visualisation; wristed instruments; precise hilar dissection',
    'SPLENIC AUTOTRANSPLANTATION (SPLENOSIS) — implant splenic fragments in greater omentum after emergency splenectomy in children → partial immunological recovery',
    'HAND-ASSISTED LAPAROSCOPIC SPLENECTOMY (HALS) — for massive spleens >20 cm',
    'ENZYME REPLACEMENT THERAPY for Gaucher\'s disease (imiglucerase/velaglucerase) — may avoid or delay splenectomy',
    'ELTROMBOPAG / ROMIPLOSTIM (TPO receptor agonists) for ITP — second-line before splenectomy; reduced need for surgery',
    'RITUXIMAB (anti-CD20) for ITP and AIHA — immunosuppression; spleen-sparing alternative',
    'CONJUGATE PNEUMOCOCCAL VACCINES (PCV13/20) — better T-cell memory than polysaccharide vaccines; preferred for asplenic patients',
]
for a in advances:
    add_bullet(a)
doc.add_paragraph()

# ══ SCORING GUIDE ══
add_heading("12. EXAMINER'S SCORING GUIDE — 30 Marks", level=1)
add_table(
    ['Section', 'Expected Marks'],
    [
        ['Surgical anatomy — position, ligaments, blood supply, microstructure, accessory spleen', '8'],
        ['Diagram: spleen relations + peritoneal ligaments (labelled)', '2'],
        ['Functions of spleen (all 7)', '2'],
        ['Splenomegaly — causes table by category', '2'],
        ["Hypersplenism — Dameshek's 4 criteria + pathophysiology", '3'],
        ['Clinical features + differentiation from kidney + investigations', '3'],
        ['Indications for splenectomy', '2'],
        ['Operative technique — open + laparoscopic steps', '3'],
        ['Complications — OPSI (organisms, mortality, prevention, vaccination)', '3'],
        ['Recent advances', '2'],
        ['TOTAL', '30'],
    ]
)
doc.add_paragraph()

add_heading('Sharp-Edge Discriminators — Mark-Winners', level=2, color=(0x2E,0x75,0xB6))
tips = [
    'Accessory spleens in 15-30%; most common site = SPLENIC HILUM (50%)',
    'Splenorenal ligament contains TAIL OF PANCREAS — injured during splenectomy → fistula/pseudocyst',
    'EARLY LIGATION of splenic artery on superior pancreatic border → autotransfusion of 200-300 mL',
    'Tuftsin = Thr-Lys-Pro-Arg (tetrapeptide) produced ONLY by spleen; absent post-splenectomy → OPSI risk',
    'OPSI mortality = 50-70%; most common organism = Streptococcus pneumoniae (50%)',
    'VACCINATION: 2 weeks BEFORE elective splenectomy; 2 weeks AFTER emergency splenectomy',
    'Prophylactic penicillin V 250 mg BD — lifelong in children; minimum 2-5 years in adults',
    'ITP: Give platelets INTRAOPERATIVELY (just before incision) — NOT pre-operatively',
    'Laparoscopic splenectomy introduced: 1991 by DELAITRE',
    "Hereditary spherocytosis: spectrin/ankyrin/band 3 defect → delay splenectomy until age 5-6",
    "Dameshek's 4 criteria (1955) for hypersplenism — ALL 4 must be present",
    "Kehr's sign = left shoulder tip pain from diaphragmatic irritation (splenic rupture/infarct)",
    'Splenomegaly distinguished from kidney: has notch, dull to percussion, NOT ballotable, moves obliquely along 10th rib',
]
for t in tips:
    add_bullet(t)
doc.add_paragraph()

p_src = doc.add_paragraph()
run_src = p_src.add_run("Sources: Current Surgical Therapy 14th Ed. (p. 698-705) | Sabiston Textbook of Surgery 21st Ed. | Bailey & Love's Short Practice of Surgery 28th Ed.")
run_src.italic = True; run_src.font.size = Pt(9)
run_src.font.color.rgb = RGBColor(0x70, 0x70, 0x70)

out_path = '/tmp/workspace/ms-surgery-notes/Spleen_Hypersplenism_30marks.docx'
doc.save(out_path)
print(f'Saved: {out_path}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()
sec = doc.sections[0]
sec.top_margin = Cm(2); sec.bottom_margin = Cm(2)
sec.left_margin = Cm(2.5); sec.right_margin = Cm(2.5)
doc.styles['Normal'].font.name = 'Arial'
doc.styles['Normal'].font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def ah(text, level=1, color=(0x1F,0x4E,0x79)):
    p = doc.add_heading(text, level=level)
    for r in p.runs: r.font.color.rgb = RGBColor(*color)
    return p

def ap(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    r = p.add_run(text); r.bold=bold; r.italic=italic; r.font.size=Pt(size)
    if color: r.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def ab(text, bold=False):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    r = p.add_run(text); r.font.size = Pt(11); r.bold = bold
    return p

def scbg(cell, hx):
    tc=cell._tc; tcPr=tc.get_or_add_tcPr()
    shd=OxmlElement('w:shd')
    shd.set(qn('w:val'),'clear'); shd.set(qn('w:color'),'auto')
    shd.set(qn('w:fill'),hx); tcPr.append(shd)

def at(headers, rows, hc='1F4E79', arc='D6E4F0'):
    tbl=doc.add_table(rows=1+len(rows), cols=len(headers))
    tbl.style='Table Grid'
    hr=tbl.rows[0].cells
    for i,h in enumerate(headers):
        hr[i].text=h; scbg(hr[i],hc)
        for p in hr[i].paragraphs:
            for r in p.runs:
                r.bold=True; r.font.size=Pt(10); r.font.color.rgb=RGBColor(0xFF,0xFF,0xFF)
    for ri,rd in enumerate(rows):
        cs=tbl.rows[ri+1].cells
        for ci,txt in enumerate(rd):
            cs[ci].text=txt
            for p in cs[ci].paragraphs:
                for r in p.runs: r.font.size=Pt(10)
        if ri%2==0:
            for c in cs: scbg(c,arc)
    return tbl

def embed_img(url, path, w=Inches(5.0), cap=None):
    try:
        r=requests.get(url,timeout=15)
        if r.status_code==200:
            with open(path,'wb') as f: f.write(r.content)
            doc.add_picture(path,width=w)
            doc.paragraphs[-1].alignment=WD_ALIGN_PARAGRAPH.CENTER
            if cap:
                c=doc.add_paragraph(cap); c.alignment=WD_ALIGN_PARAGRAPH.CENTER
                c.runs[0].italic=True; c.runs[0].font.size=Pt(9)
    except:
        ap(f'[Image: {cap}]',italic=True,color=(0x70,0x70,0x70))

# COVER
p=doc.add_paragraph(); p.alignment=WD_ALIGN_PARAGRAPH.CENTER
r=p.add_run('MS GENERAL SURGERY — EXAM NOTES')
r.bold=True; r.font.size=Pt(18); r.font.color.rgb=RGBColor(0x1F,0x4E,0x79)
p2=doc.add_paragraph(); p2.alignment=WD_ALIGN_PARAGRAPH.CENTER
r2=p2.add_run('Renal Malignancies — RCC & Wilms\' Tumour — 30-Mark Question')
r2.bold=True; r2.font.size=Pt(14); r2.font.color.rgb=RGBColor(0x2E,0x75,0xB6)
p3=doc.add_paragraph(); p3.alignment=WD_ALIGN_PARAGRAPH.CENTER
r3=p3.add_run("Sources: Campbell-Walsh-Wein Urology | Sabiston 21st Ed. | Robbins Pathology 10th Ed. | Bailey & Love 28th Ed.")
r3.italic=True; r3.font.size=Pt(10); r3.font.color.rgb=RGBColor(0x70,0x70,0x70)
doc.add_paragraph()
pq=doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Classify renal malignancies. Describe pathology, clinical features, investigations, staging and management of Renal Cell Carcinoma. Write a short note on Wilms\' tumour."   [30 Marks]').bold=True
pq.runs[0].font.size=Pt(11); pq.runs[0].font.color.rgb=RGBColor(0x7B,0x22,0x00)
doc.add_paragraph()

embed_img(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_05a923a6dad1818355e81e3baa5210e05b3bb3592e1892ee57fe52ed33d540f7.jpg',
    '/tmp/workspace/ms-surgery-notes/rcc_ct_gross.jpg',
    w=Inches(5.5),
    cap='Figure: RCC — CT scan showing heterogeneously enhancing right renal mass (top left); 3D VRT reconstruction (top right); gross radical nephrectomy specimen bisected showing large dark-brown haemorrhagic mass (bottom right). (Campbell-Walsh-Wein Urology / PMC)'
)
doc.add_paragraph()

# ═══ SECTION 1: CLASSIFICATION ═══
ah('1. CLASSIFICATION OF RENAL MALIGNANCIES', level=1)
at(
    ['Type','Origin','Frequency','Age Group'],
    [
        ['RENAL CELL CARCINOMA (RCC)\n/ Hypernephroma / Grawitz tumour','Proximal tubular epithelium','85% of all renal malignancies','Adults 50-70 yr; Male:Female = 2:1'],
        ['TRANSITIONAL CELL CARCINOMA (TCC)\nof renal pelvis','Urothelium (transitional epithelium)','8-10%','Adults 60-70 yr; associated with phenacetin, smoking'],
        ["WILMS' TUMOUR (Nephroblastoma)",'Metanephric blastema','5-6%; most common renal tumour in CHILDREN','Children 1-5 yr; peak 3-4 yr; M=F'],
        ['Squamous Cell Carcinoma of renal pelvis','Squamous metaplasia of urothelium','<1%','Associated with staghorn calculi, chronic infection'],
        ['Sarcoma (Leiomyosarcoma)','Mesenchymal elements','Rare','Adults'],
        ['Secondary (metastatic) to kidney','Lung, breast, melanoma most common','Secondary more common than primary lymphoma','Any age'],
    ]
)
doc.add_paragraph()

# ═══ SECTION 2: RCC DEFINITION & SUBTYPES ═══
ah('2. RENAL CELL CARCINOMA (RCC)', level=1)
ap('DEFINITION: Malignant tumour arising from PROXIMAL CONVOLUTED TUBULAR EPITHELIUM of the renal cortex. Also called HYPERNEPHROMA (historical — Grawitz, 1883, wrongly thought to arise from adrenal rest cells → also "Grawitz tumour").', bold=True, color=(0x1F,0x4E,0x79))
doc.add_paragraph()
ab('Incidence: 3rd most common urological cancer (after prostate + bladder cancer)')
ab('Male:Female = 2:1; Peak age: 50-70 years')
ab('5-year survival: Stage I = 95%; Stage IV = 10-15%')
doc.add_paragraph()

ah('Histological Subtypes (WHO Classification)', level=2, color=(0x2E,0x75,0xB6))
at(
    ['Subtype','Frequency','Microscopy / Gross','Molecular Driver','Prognosis'],
    [
        ['CLEAR CELL RCC (ccRCC)','70-75%','Clear cytoplasm (lipid/glycogen washed out in processing); golden-yellow gross cut surface; rich sinusoidal vascularity (chicken-wire)','VHL gene (3p25) deletion/mutation → HIF-1α accumulation → VEGF/PDGF overexpression','Intermediate; most studied'],
        ['PAPILLARY RCC','10-15%','Papillary/tubulo-papillary architecture; foamy macrophages; Type 1 (basophilic) vs Type 2 (eosinophilic)','MET proto-oncogene (Type 1); CDKN2A loss (Type 2)','Type 1: Good; Type 2: Aggressive'],
        ['CHROMOPHOBE RCC','5%','Large pale cells with distinct borders ("plant cell" appearance); perinuclear halo; raisinoid nuclei','PTEN + TP53 mutations','BEST prognosis of all subtypes'],
        ['COLLECTING DUCT (Bellini duct) carcinoma','<1%','Aggressive infiltrating pattern; tubular architecture','—','Very poor'],
        ['SARCOMATOID dedifferentiation','Any subtype (~5%)','Spindle cells; high nuclear grade; arises within any subtype','TP53, CDKN2A, NF2','Very poor; median OS <1 year'],
    ]
)
doc.add_paragraph()
ap('VHL Pathway — KEY FOR TARGETED THERAPY:', bold=True, color=(0xC0,0x00,0x00))
ab('Normal: VHL protein ubiquitinates HIF-1α → proteasomal degradation → low VEGF/PDGF')
ab('RCC: VHL MUTATION/DELETION → HIF-1α ACCUMULATES → VEGF + PDGF + TGF-α overexpressed → tumour angiogenesis + growth')
ab('This is the target of: SUNITINIB, SORAFENIB, PAZOPANIB (anti-VEGFR TKIs) and BEVACIZUMAB (anti-VEGF antibody)')
doc.add_paragraph()

# ═══ SECTION 3: RISK FACTORS ═══
ah('3. RISK FACTORS', level=1)
at(
    ['Risk Factor','Mechanism / Association'],
    [
        ['SMOKING (most important modifiable)','Doubles risk; dose-dependent; MOST IMPORTANT preventable risk factor'],
        ['OBESITY (BMI >30)','Adipokine + hormonal effects; increases risk by 30-60%'],
        ['HYPERTENSION','Independent risk factor; mechanism unclear'],
        ['ACQUIRED CYSTIC KIDNEY DISEASE','Dialysis patients — 30-50× elevated risk'],
        ['VON HIPPEL-LINDAU DISEASE (VHL)','Autosomal dominant; VHL gene 3p25; bilateral multifocal clear cell RCC; also haemangioblastomas + phaeochromocytoma + retinal angiomas'],
        ['HEREDITARY PAPILLARY RCC','MET proto-oncogene mutation; bilateral papillary RCC'],
        ["BIRT-HOGG-DUBÉ SYNDROME",'FLCN gene; chromophobe RCC + renal oncocytoma + pulmonary cysts'],
        ['TUBEROUS SCLEROSIS','Angiomyolipoma + RCC'],
        ['OCCUPATIONAL EXPOSURE','Trichloroethylene, cadmium, asbestos'],
        ['ANALGESIC NEPHROPATHY','Phenacetin → TCC of renal pelvis (not RCC)'],
    ]
)
doc.add_paragraph()

# ═══ SECTION 4: CLINICAL FEATURES ═══
ah('4. CLINICAL FEATURES', level=1)
ap("CLASSIC TRIAD (Virchow's Triad) — present in <10% of cases today:", bold=True, color=(0xC0,0x00,0x00))
ab('1. HAEMATURIA — painless, total, intermittent')
ab('2. LOIN PAIN / flank pain')
ab('3. PALPABLE LOIN MASS')
ap('TODAY: 50-60% of RCCs are detected INCIDENTALLY on ultrasound/CT done for unrelated indications.', bold=True)
doc.add_paragraph()

ah('Symptoms', level=2, color=(0x2E,0x75,0xB6))
at(
    ['Symptom','Notes'],
    [
        ['HAEMATURIA','Gross (visible) painless haematuria — most common presenting symptom (60%); total haematuria (throughout stream)'],
        ['Loin / flank pain','Dull ache from capsular distension; or sudden severe pain from haemorrhage within tumour/cyst'],
        ['Palpable loin mass','Large tumours; firm, bimanually ballotable in flanks (retroperitoneal origin)'],
        ['Weight loss, anorexia, fever','Systemic symptoms; fever may mimic PUO (pyrexia of unknown origin) — 20%'],
        ['LEFT-SIDED VARICOCELE\n(CLASSIC SIGN)', 'Left testicular vein drains into LEFT RENAL VEIN → RCC thrombus obstructs renal vein → varicocele that DOES NOT EMPTY ON LYING DOWN (secondary varicocele). Distinguishes from idiopathic varicocele (empties on lying)'],
        ['Bilateral ankle oedema','IVC obstruction by tumour thrombus (T3b/T3c)'],
    ]
)
doc.add_paragraph()

ah('Paraneoplastic Syndromes (HIGH YIELD — unique to RCC)', level=2, color=(0x2E,0x75,0xB6))
ap('Mnemonic: "PERSH + Fever" — Polycythaemia, Erythrocytosis (EPO), Renin↑ (HTN), Stauffer\'s syndrome, Hypercalcaemia + Fever', bold=True, color=(0x1F,0x4E,0x79))
at(
    ['Syndrome','Cause','Frequency'],
    [
        ['ERYTHROCYTOSIS\n(polycythaemia)','Ectopic EPO production by tumour → raised Hb + haematocrit','1-5%'],
        ['HYPERCALCAEMIA','Ectopic PTHrP production; osteolytic metastases; local cytokines','10-20%'],
        ['HYPERTENSION','Ectopic RENIN secretion; renal artery compression by tumour','40%'],
        ["STAUFFER'S SYNDROME", 'Reversible NON-METASTATIC hepatic dysfunction (elevated LFTs, hepatomegaly) WITHOUT liver metastases. NORMALISES after nephrectomy — DIAGNOSTIC FEATURE','10-15%'],
        ['FEVER (PUO pattern)','Endogenous pyrogens (IL-6, IL-1); "Pel-Ebstein-like" intermittent fever','20%'],
        ['ANAEMIA\n(normochromic, normocytic)','Haemolysis + systemic inflammation (despite EPO in some cases)','30-40%'],
        ['CUSHING\'S SYNDROME','Ectopic ACTH production','Rare'],
        ['AMYLOIDOSIS','Secondary amyloid (SAA overproduction)','Rare'],
    ]
)
doc.add_paragraph()

# ═══ SECTION 5: INVESTIGATIONS ═══
ah('5. INVESTIGATIONS', level=1)
at(
    ['Investigation','Role / Findings'],
    [
        ['Urinalysis','Haematuria (micro or macro); no casts (unlike glomerulonephritis)'],
        ['FBC','Anaemia (commonest) OR polycythaemia (EPO-secreting tumour); elevated ESR'],
        ['LFTs','Elevated in Stauffer\'s syndrome (non-metastatic hepatic dysfunction)'],
        ['Serum calcium','Elevated in PTHrP-mediated hypercalcaemia (10-20%)'],
        ['Serum creatinine / eGFR','Baseline renal function; critical for planning nephrectomy vs partial nephrectomy'],
        ['Serum LDH','Prognostic marker (part of IMDC / MSKCC prognostic score for metastatic RCC)'],
        ['ULTRASOUND ABDOMEN\n(first-line)','Confirms solid vs cystic mass; Bosniak classification for cysts; renal vein assessment; guides biopsy'],
        ['CT ABDOMEN + PELVIS\n(GOLD STANDARD FOR STAGING)','Three-phase CT: non-contrast + arterial + venous (+ delayed/urographic). Measures enhancement (>15-20 HU = solid, suspicious). Assesses: tumour extent, renal vein/IVC involvement (level of thrombus), lymph nodes, adrenal glands, contralateral kidney. TNM staging.'],
        ['CT CHEST','Lung metastases ("cannonball" lesions) — most common site of mets'],
        ['MRI ABDOMEN','SUPERIOR to CT for ASSESSING LEVEL OF IVC THROMBUS above/below diaphragm; pregnancy; iodine allergy; solves equivocal CT'],
        ['Renal arteriography','Pre-operative embolisation for large/bleeding tumours; defines vascular anatomy'],
        ['Bone scan (Tc-99m MDP)','Only if bone metastases suspected (bone pain, elevated ALP)'],
        ['Renal biopsy (US-guided)','Small renal masses (<4 cm) when diagnosis uncertain before thermal ablation; not routinely required if imaging diagnostic'],
    ]
)
doc.add_paragraph()

# ═══ SECTION 6: STAGING ═══
ah('6. STAGING', level=1)
ah("Robson's Staging (Traditional — Still Used in MS Exams)", level=2, color=(0x2E,0x75,0xB6))
at(
    ['Stage','Description','5-Year Survival'],
    [
        ['I','Tumour confined WITHIN the renal capsule','66%'],
        ['II','Extension to perinephric fat but WITHIN GEROTA\'S FASCIA','55%'],
        ['III A','Renal vein OR IVC involvement (venous spread)','40%'],
        ['III B','Regional LYMPH NODE involvement','20-30%'],
        ['III C','Both venous + lymph node involvement','20%'],
        ['IV A','Invasion of adjacent organs (EXCLUDING ipsilateral adrenal)','5-15%'],
        ['IV B','Distant METASTASES (lung, bone, brain, liver)','5-10%'],
    ]
)
doc.add_paragraph()

ah('TNM Staging — AJCC 8th Edition (Current Standard)', level=2, color=(0x2E,0x75,0xB6))
at(
    ['TNM','Description'],
    [
        ['T1a','Tumour ≤4 cm, limited to kidney'],
        ['T1b','Tumour 4-7 cm, limited to kidney'],
        ['T2a','Tumour 7-10 cm, limited to kidney'],
        ['T2b','Tumour >10 cm, limited to kidney'],
        ['T3a','Into renal vein branch / perinephric fat / renal sinus fat / adrenal (within Gerota\'s)'],
        ['T3b','Into IVC BELOW DIAPHRAGM'],
        ['T3c','Into IVC ABOVE DIAPHRAGM or right atrium'],
        ['T4','Beyond Gerota\'s fascia (invasion of adjacent organs)'],
        ['N0/N1','No nodal mets / Regional node mets'],
        ['M0/M1','No distant mets / Distant metastases'],
        ['Stage I = T1N0M0','95% 5-year survival'],
        ['Stage II = T2N0M0','80% 5-year survival'],
        ['Stage III = T3 OR T1-3 N1 M0','55-60% 5-year survival'],
        ['Stage IV = T4 any N M0 OR any T any N M1','10-15% 5-year survival'],
    ]
)
doc.add_paragraph()
ap('WHO/ISUP Nuclear Grade (1-4): Grade 1 = small regular inconspicuous nucleoli; Grade 4 = extreme pleomorphism, sarcomatoid change. Higher grade = worse prognosis.', bold=True)
doc.add_paragraph()

# ═══ SECTION 7: MANAGEMENT ═══
ah('7. MANAGEMENT', level=1)

ah('A. Localised Disease (Stage I-III) — Surgical (Curative Intent)', level=2, color=(0x2E,0x75,0xB6))
ap('1. RADICAL NEPHRECTOMY (Gold Standard for T2 + T3):', bold=True, color=(0x1F,0x4E,0x79))
at(
    ['Feature','Detail'],
    [
        ['What is removed','Kidney + Gerota\'s fascia + perinephric fat + ipsilateral adrenal (if involved) + regional lymph nodes'],
        ['Approach','Open: midline/flank/thoracoabdominal. LAPAROSCOPIC radical nephrectomy (preferred T1-T2): equivalent oncological outcomes, less blood loss, shorter stay, faster recovery'],
        ['KEY STEP','EARLY LIGATION OF RENAL ARTERY before mobilising kidney — prevents haematogenous dissemination; reduces tumour congestion'],
        ['IVC thrombus (T3b)','IVC thrombectomy + vascular surgery; caval clamping below hepatic veins'],
        ['IVC thrombus above diaphragm (T3c)','CARDIOPULMONARY BYPASS (CPB) + cardiac surgery required for right atrial thrombus — refer to cardiothoracic surgery'],
    ]
)
doc.add_paragraph()

ap('2. PARTIAL NEPHRECTOMY / NEPHRON-SPARING SURGERY (NSS):', bold=True, color=(0x1F,0x4E,0x79))
at(
    ['Indication Type','Examples'],
    [
        ['ABSOLUTE indications\n(must do NSS)','Solitary kidney (anatomical or functional); Bilateral synchronous RCC; Renal insufficiency (CKD stage 3+)'],
        ['RELATIVE indications','Opposite kidney at risk (diabetes, hypertension, urolithiasis, reflux nephropathy)'],
        ['ELECTIVE indication\n(preferred standard of care)','T1a (≤4 cm) — NCCN + EAU recommend NSS over radical nephrectomy for T1a: equivalent oncological outcomes; preserves renal function; reduces risk of cardiovascular events + CKD'],
    ]
)
ab('Robotic partial nephrectomy: most precise; warm ischaemia time <25 minutes target; preserves maximal parenchyma')
ab('Complications: urinary fistula (1-2%), haemorrhage, AKI, tumour margin positivity')
doc.add_paragraph()

ap('3. Ablative Therapies (small tumours, poor surgical candidates):', bold=True, color=(0x1F,0x4E,0x79))
at(
    ['Technique','Detail'],
    [
        ['Radiofrequency Ablation (RFA)','Heat-based tumour destruction; percutaneous US/CT-guided; for T1a ≤3 cm; 5-yr local control 90%'],
        ['Cryoablation','Freeze-thaw cycles; laparoscopic or percutaneous; comparable to RFA'],
        ['HIFU (High-Intensity Focussed Ultrasound)','Newer; limited evidence'],
    ]
)
doc.add_paragraph()

ah('B. Metastatic RCC (Stage IV) — Systemic Therapy', level=2, color=(0x2E,0x75,0xB6))
ap('Historical: IL-2 + Interferon-α (largely replaced by targeted therapy + immunotherapy)', italic=True)
doc.add_paragraph()

ap('Targeted Therapy (VHL/HIF/VEGF pathway):', bold=True, color=(0x1F,0x4E,0x79))
at(
    ['Drug','Class','Target','Notes'],
    [
        ['SUNITINIB','TKI (tyrosine kinase inhibitor)','VEGFR 1,2,3 + PDGFR + cKIT','Standard first-line for favourable risk (NCCN); oral; improved PFS vs IFN-α'],
        ['PAZOPANIB','TKI','VEGFR 1,2,3 + PDGFR + cKIT','Non-inferior to sunitinib (COMPARZ trial); better GI tolerability'],
        ['CABOZANTINIB','TKI','VEGFR 2 + MET + AXL','Preferred for intermediate/poor risk first-line; also second-line (METEOR trial)'],
        ['SORAFENIB','TKI','VEGFR 2 + RAF + PDGFR','Now second-line; first approved TKI for mRCC'],
        ['AXITINIB','TKI (selective VEGFR 1,2,3)','VEGFR 1,2,3','Second-line; combined with pembrolizumab for first-line IO+TKI'],
        ['EVEROLIMUS, TEMSIROLIMUS','mTOR inhibitors','mTOR complex 1','Second-line; temsirolimus for poor-prognosis first-line (historical)'],
        ['BEVACIZUMAB','Anti-VEGF monoclonal antibody','VEGF-A','With IFN-α (historical combination)'],
    ]
)
doc.add_paragraph()

ap('Immunotherapy — Checkpoint Inhibitors (CURRENT STANDARD):', bold=True, color=(0xC0,0x00,0x00))
at(
    ['Regimen','Drugs','Mechanism','Key Trial + Outcome'],
    [
        ['NIVOLUMAB + IPILIMUMAB\n(PREFERRED for int/poor risk)','Anti-PD-1 + Anti-CTLA-4','Dual checkpoint blockade; unleashes T-cell anti-tumour immunity','CheckMate 214: superior OS vs sunitinib for intermediate/poor risk; ORR 42%; complete response 9%'],
        ['PEMBROLIZUMAB + AXITINIB\n(PREFERRED across all risk groups)','Anti-PD-1 + VEGFR TKI','IO + anti-VEGF synergy','KEYNOTE-426: superior PFS + OS vs sunitinib across ALL risk groups; now NCCN Category 1'],
        ['NIVOLUMAB + CABOZANTINIB','Anti-PD-1 + TKI (VEGFR/MET/AXL)','IO + TKI','CheckMate 9ER: superior PFS + OS vs sunitinib'],
        ['NIVOLUMAB (monotherapy)','Anti-PD-1','PD-1/PD-L1 checkpoint inhibition','Second-line after TKI failure (CheckMate 025): superior OS vs everolimus; ORR 25%'],
    ]
)
doc.add_paragraph()

ap('CARMENA TRIAL (2018) — LANDMARK:', bold=True, color=(0xC0,0x00,0x00))
ab('CARMENA trial: Sunitinib alone NON-INFERIOR to cytoreductive nephrectomy + sunitinib in intermediate/poor risk metastatic RCC')
ab('IMPLICATION: Routine cytoreductive nephrectomy is NO LONGER standard of care for intermediate/poor risk patients — individualised decision')
ab('Still considered for selected favourable-risk patients with good PS + limited metastatic burden')
doc.add_paragraph()

ap('Bone Metastases (osteolytic):', bold=True)
ab('Denosumab (anti-RANK-L) or Zoledronic acid — reduces skeletal-related events')
ab('Surgical stabilisation for impending pathological fractures')
ab('Stereotactic body radiotherapy (SBRT) for oligometastases — RCC is relatively radioresistant to conventional fractionation')
doc.add_paragraph()

# ═══ SECTION 8: WILMS TUMOUR ═══
ah("8. WILMS' TUMOUR (NEPHROBLASTOMA)", level=1)
ap("DEFINITION: Most common renal malignancy in CHILDREN; most common abdominal malignancy in children. Arises from METANEPHRIC BLASTEMA (primitive renal anlage). One of the great success stories of paediatric oncology — overall survival >90%.", bold=True)
doc.add_paragraph()
ab("Peak age: 3-4 years (range 1-5 years); rare after 10 years")
ab("Male = Female (equal sex distribution — unlike RCC)")
ab("Bilateral in 5-10% of cases")
doc.add_paragraph()

ah('Associated Syndromes (WT1 + WT2 genes)', level=2, color=(0x2E,0x75,0xB6))
at(
    ['Syndrome','Features','Gene'],
    [
        ['WAGR SYNDROME','Wilms\' tumour + Aniridia + Genitourinary anomalies + mental Retardation','WT1 gene DELETION (11p13)'],
        ['BECKWITH-WIEDEMANN SYNDROME','Macroglossia + Organomegaly + Omphalocele + Gigantism + Hemihypertrophy','WT2 locus (11p15); IGF-2 overexpression'],
        ['DENYS-DRASH SYNDROME','Wilms\' + Gonadal dysgenesis + Nephropathy (mesangial sclerosis)','WT1 POINT MUTATION'],
        ['SPORADIC WILMS\'','No associated syndrome (~85%)','WT1 OR WT2 OR other loci'],
    ]
)
doc.add_paragraph()

ah('Pathology', level=2, color=(0x2E,0x75,0xB6))
ap('Gross: Large, unilateral, smooth-surfaced tumour; pseudocapsule; pale grey/fish-flesh cut surface with haemorrhage/necrosis.', bold=False)
doc.add_paragraph()
ap('CLASSIC TRIPHASIC MICROSCOPIC PATTERN:', bold=True, color=(0xC0,0x00,0x00))
at(
    ['Component','Cells','Feature'],
    [
        ['1. BLASTEMAL','Small, blue, round, undifferentiated cells','Most aggressive histology; worst prognosis if predominant'],
        ['2. STROMAL','Fibrous + smooth muscle + cartilage + bone + fat','Differentiation; varying maturity'],
        ['3. EPITHELIAL','Form tubules + glomeruloid structures','Recapitulates nephrogenesis'],
    ]
)
doc.add_paragraph()
ap('Histological Risk:', bold=True)
ab('FAVOURABLE HISTOLOGY (FH): Classic triphasic pattern — 90%; excellent prognosis', bold=True)
ab('UNFAVOURABLE / ANAPLASTIC HISTOLOGY (UH): Nuclear anaplasia (3× enlarged nuclei + multipolar mitoses) — 10%; DIFFUSE anaplasia = worst; requires intensified therapy')
doc.add_paragraph()

ah('Clinical Features', level=2, color=(0x2E,0x75,0xB6))
at(
    ['Feature','Notes'],
    [
        ['ABDOMINAL MASS\n(most common — 90%)', 'Smooth, firm, non-tender; DOES NOT CROSS MIDLINE (unlike neuroblastoma); discovered by parent during bathing/dressing; not associated with weight loss early'],
        ['HYPERTENSION','Renin secretion; 25-60% of patients'],
        ['Haematuria','Less prominent than RCC; microscopic haematuria in ~25%'],
        ['Abdominal pain','After haemorrhage into tumour'],
        ['Fever, anorexia','Systemic symptoms in larger tumours'],
    ]
)
doc.add_paragraph()

ah("Distinguishing Wilms' Tumour from NEUROBLASTOMA (CRITICAL EXAM DISTINCTION)", level=2, color=(0x2E,0x75,0xB6))
at(
    ['Feature','Wilms\' Tumour','Neuroblastoma'],
    [
        ['Origin','KIDNEY (renal; metanephric blastema)','ADRENAL MEDULLA / sympathetic chain'],
        ['Age','1-5 years (OLDER)','<2 years (YOUNGER)'],
        ['Abdominal mass','SMOOTH; DOES NOT CROSS MIDLINE','IRREGULAR; CROSSES MIDLINE; nodular'],
        ['Haematuria','PRESENT (25%)','ABSENT'],
        ['Calcification on imaging','ABSENT (rare)','PRESENT in 70-80% (stippled/dense)'],
        ['Urinary VMA / HVA\n(catecholamines)','NORMAL','ELEVATED (diagnostic)'],
        ['Anaemia','Mild','SEVERE'],
        ['CT / IVU finding','INTRARENAL mass; displaces pelvi-calyceal system inward ("claw sign")','EXTRINSIC mass; kidney displaced DOWNWARD AND LATERALLY'],
        ['Prognosis','EXCELLENT (>90% survival Stage I-III)','POOR (30-40% Stage IV)'],
    ]
)
doc.add_paragraph()

ah('Staging (NWTS / COG Staging)', level=2, color=(0x2E,0x75,0xB6))
at(
    ['Stage','Description','5-Year Survival'],
    [
        ['I','Tumour limited to kidney; completely excised; capsule intact; no spill','>95%'],
        ['II','Tumour extends beyond kidney (perinephric fat / vessel outside renal sinus); completely excised','95%'],
        ['III','Residual non-haematogenous tumour post-surgery; positive lymph nodes; peritoneal spill; incomplete excision; pre-op biopsy (OPEN)','85-90%'],
        ['IV','Haematogenous metastases (lung, liver, bone, brain)','85-90% (lung mets retain high survival with WLI)'],
        ['V','BILATERAL WILMS\' TUMOUR (synchronous)','Variable; nephron-sparing bilateral approach'],
    ]
)
doc.add_paragraph()

ah('Management — Multimodal', level=2, color=(0x2E,0x75,0xB6))
ap('North American Approach (NWTS/COG): SURGERY FIRST then post-op chemo ± RT based on stage + histology', bold=True, color=(0x1F,0x4E,0x79))
ap('European Approach (SIOP): PRE-OPERATIVE CHEMOTHERAPY first → nephrectomy → adjuvant chemo ± RT (reduces tumour size + rupture risk)', bold=True, color=(0x1F,0x4E,0x79))
doc.add_paragraph()
at(
    ['Step','North American (NWTS/COG) Protocol'],
    [
        ['1. Primary Nephrectomy','Via transperitoneal approach; examine contralateral kidney; lymph node sampling; avoid rupture (Stage III if spill)'],
        ['2. Post-op Chemotherapy (ALL stages)','Stage I/II FH: VINCRISTINE + ACTINOMYCIN D (18 weeks)\nStage III/IV FH: Add DOXORUBICIN\nAnaplastic (UH): Add CYCLOPHOSPHAMIDE + ETOPOSIDE + CARBOPLATIN'],
        ['3. Radiotherapy','Stage III FH: Flank RT (10.8 Gy)\nAll anaplastic: Flank RT\nStage IV with pulmonary mets not achieving CR: WHOLE LUNG IRRADIATION (WLI) 12 Gy\nStage III peritoneal spill: Whole abdomen RT'],
        ['4. Bilateral (Stage V)','Pre-op chemo → BILATERAL PARTIAL NEPHRECTOMIES (sparing as much parenchyma as possible) → adjuvant chemo ± RT'],
    ]
)
doc.add_paragraph()

# ═══ SECTION 9: TCC RENAL PELVIS ═══
ah('9. TCC OF RENAL PELVIS (Short Note)', level=1)
ab('8-10% of renal tumours; associated with analgesic nephropathy (phenacetin), smoking, Balkan endemic nephropathy, occupational carcinogens')
ab('Field change effect — synchronous/metachronous TCC in ureter + bladder (examine entire urothelium)')
ab('IVU: Filling defect in renal pelvis — irregular = TCC; smooth = clot/calculus')
ab('Management: NEPHROURETERECTOMY WITH CUFF OF BLADDER (distal ureter not left in situ — risk of TCC in stump); laparoscopic or open')
ab('Follow-up: Cystoscopy every 3 months for 2 years (bladder TCC risk)')
doc.add_paragraph()

# ═══ SECTION 10: RECENT ADVANCES ═══
ah('10. RECENT ADVANCES', level=1)
advances = [
    'ROBOTIC PARTIAL NEPHRECTOMY — gold standard for T1a/T1b; warm ischaemia time <25 min; better precision at hilum; improved functional outcomes',
    'DUAL CHECKPOINT BLOCKADE (nivolumab + ipilimumab) — superior OS for intermediate/poor risk metastatic ccRCC (CheckMate 214)',
    'IO + TKI COMBINATIONS (pembrolizumab + axitinib / nivolumab + cabozantinib) — improved PFS + OS across all risk groups',
    'CARMENA TRIAL (2018) — cytoreductive nephrectomy role redefined; sunitinib alone non-inferior in intermediate/poor risk',
    'BIOMARKERS — PD-L1 expression, gene expression signatures, IMDC risk score for treatment selection',
    'ACTIVE SURVEILLANCE for small renal masses (T1a <2 cm in elderly/poor surgical candidates) — growth rate 0.3 cm/year; <2% metastasis rate in surveillance cohort',
    'IMMUNOTHERAPY IN ADJUVANT SETTING — Pembrolizumab (KEYNOTE-564): first IO to show improved DFS after nephrectomy for high-risk localised/locally advanced RCC',
    "WILMS' TUMOUR — UMBRELLA/SIOP 2016 Protocol: risk-stratified chemotherapy based on blastemal tumour % in post-chemo specimen; biological risk stratification using LOH 1p/16q",
    'NEXT-GENERATION SEQUENCING (NGS) — identifying MTOR pathway mutations, BAP1, SETD2 for prognostication and targeted therapy selection',
]
for a in advances: ab(a)
doc.add_paragraph()

# ═══ SCORING ═══
ah("11. EXAMINER'S SCORING GUIDE — 30 Marks", level=1)
at(
    ['Section','Expected Marks'],
    [
        ['Classification of renal malignancies (table with all types)','2'],
        ['RCC subtypes (5 types) + VHL molecular pathway','4'],
        ['Risk factors','2'],
        ['Clinical features — triad + paraneoplastic syndromes (ALL syndromes with mechanism)','4'],
        ['Investigations + Robson staging + TNM staging (BOTH tables)','5'],
        ["Management — surgery (radical/partial + IVC thrombus + CPB)","4"],
        ['Targeted therapy + immunotherapy (named drugs + key trials)','3'],
        ["Wilms' tumour (pathology + triphasic + staging + management + vs neuroblastoma)","5"],
        ['Recent advances','1'],
        ['TOTAL','30'],
    ]
)
doc.add_paragraph()

ah('Sharp-Edge Discriminators — Mark-Winners', level=2, color=(0x2E,0x75,0xB6))
tips = [
    'HYPERNEPHROMA / GRAWITZ TUMOUR (1883) — historical name; arises from PROXIMAL TUBULAR EPITHELIUM, NOT adrenal',
    'LEFT VARICOCELE that does NOT empty on lying down = pathognomonic of left RCC with renal vein thrombosis',
    "STAUFFER'S SYNDROME = non-metastatic hepatic dysfunction; NORMALISES after nephrectomy — unique to RCC",
    'VHL gene (3p25) → HIF-1α accumulation → VEGF overexpression → target of sunitinib/pazopanib',
    'IVC thrombus above diaphragm (T3c) = requires CARDIOPULMONARY BYPASS + cardiac surgery',
    'CARMENA TRIAL (2018): sunitinib alone non-inferior to cytoreductive nephrectomy + sunitinib',
    'CheckMate 214: nivolumab + ipilimumab superior OS for intermediate/poor risk metastatic RCC',
    'KEYNOTE-426: pembrolizumab + axitinib superior across ALL risk groups — NCCN Category 1',
    "Wilms' tumour: WT1 gene (WAGR syndrome, 11p13); WT2 gene (Beckwith-Wiedemann, 11p15)",
    "Wilms' TRIPHASIC pattern: Blastemal + Stromal + Epithelial cells",
    "Wilms' vs Neuroblastoma: SMOOTH/does NOT cross midline vs IRREGULAR/CROSSES midline; VMA NORMAL vs ELEVATED",
    "NWTS Stage I Wilms' = >95% 5-year survival — one of best-prognosis paediatric solid tumours",
    "Adjuvant pembrolizumab post-nephrectomy (KEYNOTE-564) — first IO to show DFS benefit in adjuvant setting",
    'PARTIAL NEPHRECTOMY preferred over radical for T1a (≤4 cm) — equivalent oncological outcomes + preserves renal function',
]
for t in tips: ab(t)
doc.add_paragraph()
ps = doc.add_paragraph()
rs = ps.add_run("Sources: Campbell-Walsh-Wein Urology (ISBN 9780323546423) | Sabiston Textbook of Surgery 21st Ed. | Robbins Pathologic Basis of Disease 10th Ed. (ISBN 9780443264528) | Bailey & Love's Short Practice of Surgery 28th Ed.")
rs.italic=True; rs.font.size=Pt(9); rs.font.color.rgb=RGBColor(0x70,0x70,0x70)

out = '/tmp/workspace/ms-surgery-notes/Renal_Malignancies_30marks.docx'
doc.save(out)
print(f'Saved: {out}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()
sec = doc.sections[0]
sec.top_margin = Cm(2); sec.bottom_margin = Cm(2)
sec.left_margin = Cm(2.5); sec.right_margin = Cm(2.5)
doc.styles['Normal'].font.name = 'Arial'
doc.styles['Normal'].font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def ah(text, level=1, color=(0x1F,0x4E,0x79)):
    p = doc.add_heading(text, level=level)
    for r in p.runs: r.font.color.rgb = RGBColor(*color)
    return p

def ap(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    r = p.add_run(text); r.bold=bold; r.italic=italic; r.font.size=Pt(size)
    if color: r.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def ab(text, bold=False):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    r = p.add_run(text); r.font.size=Pt(11); r.bold=bold
    return p

def scbg(cell, hx):
    tc=cell._tc; tcPr=tc.get_or_add_tcPr()
    shd=OxmlElement('w:shd')
    shd.set(qn('w:val'),'clear'); shd.set(qn('w:color'),'auto')
    shd.set(qn('w:fill'),hx); tcPr.append(shd)

def at(headers, rows, hc='1F4E79', arc='D6E4F0'):
    tbl=doc.add_table(rows=1+len(rows), cols=len(headers))
    tbl.style='Table Grid'
    hr=tbl.rows[0].cells
    for i,h in enumerate(headers):
        hr[i].text=h; scbg(hr[i],hc)
        for p in hr[i].paragraphs:
            for r in p.runs:
                r.bold=True; r.font.size=Pt(10); r.font.color.rgb=RGBColor(0xFF,0xFF,0xFF)
    for ri,rd in enumerate(rows):
        cs=tbl.rows[ri+1].cells
        for ci,txt in enumerate(rd):
            cs[ci].text=txt
            for p in cs[ci].paragraphs:
                for r in p.runs: r.font.size=Pt(10)
        if ri%2==0:
            for c in cs: scbg(c,arc)
    return tbl

def embed_img(url, path, w=Inches(5.0), cap=None):
    try:
        r=requests.get(url,timeout=15)
        if r.status_code==200:
            with open(path,'wb') as f: f.write(r.content)
            doc.add_picture(path,width=w)
            doc.paragraphs[-1].alignment=WD_ALIGN_PARAGRAPH.CENTER
            if cap:
                c=doc.add_paragraph(cap); c.alignment=WD_ALIGN_PARAGRAPH.CENTER
                c.runs[0].italic=True; c.runs[0].font.size=Pt(9)
    except:
        ap(f'[Image: {cap}]',italic=True,color=(0x70,0x70,0x70))

# COVER
p=doc.add_paragraph(); p.alignment=WD_ALIGN_PARAGRAPH.CENTER
r=p.add_run('MS GENERAL SURGERY — EXAM NOTES')
r.bold=True; r.font.size=Pt(18); r.font.color.rgb=RGBColor(0x1F,0x4E,0x79)
p2=doc.add_paragraph(); p2.alignment=WD_ALIGN_PARAGRAPH.CENTER
r2=p2.add_run('Gastric Outlet Obstruction (GOO) — 30-Mark Question')
r2.bold=True; r2.font.size=Pt(14); r2.font.color.rgb=RGBColor(0x2E,0x75,0xB6)
p3=doc.add_paragraph(); p3.alignment=WD_ALIGN_PARAGRAPH.CENTER
r3=p3.add_run("Sources: Fischer's Mastery of Surgery 8th Ed. | Yamada's Gastroenterology 7th Ed. | Sabiston 21st Ed. | Schwartz's Surgery 11th Ed.")
r3.italic=True; r3.font.size=Pt(10); r3.font.color.rgb=RGBColor(0x70,0x70,0x70)
doc.add_paragraph()
pq=doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Define Gastric Outlet Obstruction. Describe its causes, pathophysiology, clinical features, investigations and management. What are the metabolic consequences and how are they corrected?"   [30 Marks]').bold=True
pq.runs[0].font.size=Pt(11); pq.runs[0].font.color.rgb=RGBColor(0x7B,0x22,0x00)
doc.add_paragraph()

embed_img(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_4f18b3f771430c675f9cb2c2ff91ca08e51e607ba1b8598abe09d7ebcdeb2a14.jpg',
    '/tmp/workspace/ms-surgery-notes/goo_barium.jpg', w=Inches(5.5),
    cap='Figure: GOO — (A) Ultrasound: distended stomach with retained contents. (B) Barium meal: grossly dilated stomach with poor distal passage — pyloric stenosis. (C-F) Endoscopy: pyloric narrowing with surrounding inflammatory changes and active ulcers. (Yamada\'s Gastroenterology / PMC)'
)
doc.add_paragraph()

# SECTION 1 ANATOMY
ah('1. SURGICAL ANATOMY OF THE STOMACH AND PYLORUS', level=1)
ap('EXAM TIP: Draw the stomach showing its 5 parts, blood supply, nerve supply and relations — scores 3-4 marks.', bold=True, color=(0xC0,0x00,0x00))

ah('Parts of the Stomach', level=2, color=(0x2E,0x75,0xB6))
at(['Part','Description','Cell Types'],
[
    ['CARDIA','Junction with oesophagus at OGJ; level T10/T11','Mucous cells (cardia glands)'],
    ['FUNDUS','Dome above cardia; left hemidiaphragm; gas bubble on X-ray','Parietal cells + Chief cells'],
    ['BODY (Corpus)','Largest part; main acid-secreting region','PARIETAL CELLS (HCl + Intrinsic Factor); CHIEF CELLS (Pepsinogen)'],
    ['ANTRUM','Distal 1/3; no parietal cells; 3-5 cm proximal to pylorus','G-CELLS (Gastrin); D-cells (Somatostatin)'],
    ['PYLORUS + CANAL','Thick-walled sphincter; 3 cm long; controls gastric emptying into D1','Mucous cells; pyloric glands'],
])
doc.add_paragraph()

ah('Blood Supply', level=2, color=(0x2E,0x75,0xB6))
at(['Vessel','Origin','Supply'],
[
    ['LEFT GASTRIC ARTERY (most important)','Coeliac axis (directly)','Lesser curvature (main supply); anastomoses with right gastric'],
    ['RIGHT GASTRIC ARTERY','Proper hepatic artery','Lesser curvature (distal)'],
    ['RIGHT GASTROEPIPLOIC ARTERY','Gastroduodenal artery (from common hepatic)','Greater curvature (right/inferior)'],
    ['LEFT GASTROEPIPLOIC ARTERY','Splenic artery','Greater curvature (left)'],
    ['SHORT GASTRIC ARTERIES (5-7)','Splenic artery (terminal branches)','FUNDUS'],
    ['GASTRODUODENAL ARTERY','Common hepatic artery','Posterior duodenal wall; ERODED BY DU → haemorrhage; "three-point ligation" if bleeding'],
])
doc.add_paragraph()

ah('Nerve Supply (Vagus) — CRITICAL FOR VAGOTOMY', level=2, color=(0x2E,0x75,0xB6))
at(['Nerve','Origin','Branches / Course','Surgical Importance'],
[
    ['ANTERIOR (LEFT) VAGAL TRUNK','Left vagus at oesophageal hiatus','Hepatobiliary + pancreatic branches; continues as ANTERIOR NERVE OF LATARJET along lesser curvature in anterior gastrohepatic omentum','Hepatic branch must be preserved; Latarjet branches supply antrum'],
    ['POSTERIOR (RIGHT) VAGAL TRUNK','Right vagus at oesophageal hiatus','Coeliac branch (pancreas/SB/colon); continues as POSTERIOR NERVE OF LATARJET','Coeliac branch must be preserved during selective vagotomy'],
    ["CROW'S FOOT (Pied de Corbe)",'Terminal branches of both nerves of Latarjet at the angulus incisura','Fan-shaped distribution to antrum and pylorus','LIMIT OF HIGHLY SELECTIVE VAGOTOMY — preserve these to maintain antral motility; cut everything proximal = HSV'],
])
ap("Source: Fischer's Mastery of Surgery 8th Ed., p. 2906", italic=True, color=(0x70,0x70,0x70), size=9)
doc.add_paragraph()

ah('Gastric Secretion', level=2, color=(0x2E,0x75,0xB6))
ab('Parietal cells: HCl (150 mEq/L) + Intrinsic Factor; stimulated by gastrin, ACh (vagus), histamine (ECL cells)')
ab('Chief cells: Pepsinogen → Pepsin (activated by acid pH <4)')
ab('G-cells (antrum): Gastrin; secretion inhibited by antral pH <2 (negative feedback)')
ab('D-cells: Somatostatin → inhibits gastrin + HCl (paracrine inhibition)')
ab('Daily gastric juice output: 2-3 LITRES — critical for understanding fluid/electrolyte losses in GOO')
doc.add_paragraph()

# SECTION 2 DEFINITION
ah('2. DEFINITION', level=1)
ap('GASTRIC OUTLET OBSTRUCTION (GOO) = a clinical syndrome resulting from any disease process that impairs the emptying of gastric contents into the duodenum, causing gastric stasis, progressive gastric dilatation, and characteristic metabolic derangements.', bold=True)
doc.add_paragraph()
ab('Obstruction may be at: pyloric canal, pyloric antrum, D1 or D2 (duodenum)')
ab('Historical: PUD accounted for 90% of GOO')
ab('NOW: Malignancy = 50-80%; PUD = only 5% in developed countries')
ab('In India / developing countries: PUD-GOO = 50-60% of surgical interventions in complicated PUD (Yamada\'s Gastroenterology 7th Ed., p. 1041)', bold=True)
doc.add_paragraph()

# SECTION 3 CAUSES
ah('3. CAUSES OF GOO', level=1)
ap('Mnemonic for benign causes: "DU PT CAP" — Duodenal Ulcer, Pyloric channel ulcer, Tuberculosis, Caustic ingestion, Adhesions/anastomotic stricture, Pancreatitis/pseudocyst', bold=True, color=(0x1F,0x4E,0x79))
at(['Category','Causes'],
[
    ['BENIGN\n(Most important exam group)','Duodenal ulcer with pyloric scarring (most common benign cause); Gastric ulcer (prepyloric/antral); Pyloric channel ulcer; H. pylori-associated scarring; Caustic ingestion (acid/alkali); TUBERCULOSIS of pylorus/duodenum; Crohn\'s disease (duodenal); Post-operative stricture; Pancreatitis/pancreatic pseudocyst (extrinsic)'],
    ['MALIGNANT\n(Most common overall in developed world)','Carcinoma of stomach (antral/pyloric — most common malignant cause); Carcinoma of pancreas (head — duodenal compression); Carcinoma of duodenum; Cholangiocarcinoma; Ampullary carcinoma; Gastric lymphoma; GIST (large antral)'],
    ['CONGENITAL\n(Paediatric group)','HYPERTROPHIC PYLORIC STENOSIS (HPS) — most common; infant 3-6 weeks; first-born male; Pyloric atresia; Duodenal atresia; Duodenal web; Annular pancreas'],
    ['MISCELLANEOUS / EXTRINSIC','Bouveret\'s syndrome (gallstone in D1 via bilioduodenal fistula); Zollinger-Ellison syndrome (~10% develop GOO); Bezoar; SMA syndrome; Adult hypertrophic pyloric stenosis'],
])
doc.add_paragraph()

# SECTION 4 PATHOPHYSIOLOGY
ah('4. PATHOPHYSIOLOGY', level=1)
ah('Sequence of Events', level=2, color=(0x2E,0x75,0xB6))
steps=[
    '1. Obstruction at pylorus/duodenum (benign: fibrosis + oedema; malignant: luminal invasion)',
    '2. Gastric stasis → stomach DILATES (compensatory gastric hypertrophy initially)',
    '3. Copious VOMITING of undigested food (hours/days after eating); NO BILE (obstruction is pre-ampullary)',
    '4. Loss in vomit: HCl (H⁺ + Cl⁻), K⁺, Na⁺, H₂O → daily loss 2-3 litres gastric juice',
    '5. HYPOCHLORAEMIC HYPOKALAEMIC HYPONATRAEMIC METABOLIC ALKALOSIS develops',
    '6. Dehydration → secondary hyperaldosteronism → renal Na⁺ retention, K⁺ wasting → worsens hypokalaemia',
    '7. PARADOXICAL ACIDURIA: Na⁺ conservation overrides acid-base → H⁺ excreted in urine despite alkalosis',
    '8. Severe dehydration → pre-renal uraemia → acute kidney injury',
    '9. Malnutrition + wasting → hypoalbuminaemia → immunocompromise',
]
for s in steps: ab(s)
doc.add_paragraph()

ah('Metabolic Consequences — COMPLETE TABLE (HIGH YIELD)', level=2, color=(0x2E,0x75,0xB6))
ap('NET RESULT: Hypochloraemic, Hypokalaemic, Hyponatraemic Metabolic Alkalosis with Dehydration and Pre-renal Uraemia', bold=True, color=(0xC0,0x00,0x00))
at(['Electrolyte / Parameter','Change','Mechanism'],
[
    ['Serum Cl⁻','↓ HYPOCHLORAEMIA','HCl lost in vomit; Cl⁻ concentration in gastric juice = 150 mEq/L (highest of any fluid)'],
    ['Serum K⁺','↓ HYPOKALAEMIA','Direct K⁺ loss in gastric juice; Secondary hyperaldosteronism (dehydration → RAAS) → renal K⁺ wasting; intracellular H⁺/K⁺ exchange'],
    ['Serum Na⁺','↓ HYPONATRAEMIA (mild)','Na⁺ loss in vomit; dilutional component; hyperaldosteronism preserves some Na⁺'],
    ['Serum HCO₃⁻','↑ ELEVATED (metabolic alkalosis)','Net H⁺ loss → relative HCO₃⁻ excess in blood; intracellular H⁺/K⁺ exchange'],
    ['Arterial pH','↑ ALKALOSIS (>7.45)','Net H⁺ loss; HCO₃⁻ accumulation'],
    ['PCO₂','↑ (respiratory compensation)','Hypoventilation to retain CO₂ and lower pH (compensatory)'],
    ['Blood Urea','↑ PRE-RENAL URAEMIA','Dehydration → reduced renal perfusion; protein catabolism (urea cycle)'],
    ['Ionised Calcium','↓ HYPOCALCAEMIA','Alkalosis → more Ca²⁺ bound to albumin → reduced ionised Ca²⁺ → TETANY (Trousseau + Chvostek)'],
    ['Urine pH (PARADOXICAL ACIDURIA)','ACIDIC urine despite alkalosis','Na⁺ conservation takes priority → renal tubule excretes H⁺ and K⁺ (H⁺/Na⁺ exchange) even in alkalosis — FINK PHENOMENON; severe depletion sign'],
])
doc.add_paragraph()
ap('PARADOXICAL ACIDURIA (Fink Phenomenon) = acidic urine (pH <5) despite systemic metabolic alkalosis. Signals SEVERE Na⁺ and volume depletion. Poor prognostic sign. Resolves with adequate resuscitation.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

# SECTION 5 CLINICAL FEATURES
ah('5. CLINICAL FEATURES', level=1)
ah('Symptoms', level=2, color=(0x2E,0x75,0xB6))
at(['Symptom','Detail'],
[
    ['VOMITING (cardinal feature)','PROJECTILE, EFFORTLESS vomiting of UNDIGESTED / PARTIALLY DIGESTED food hours/days after eating; LARGE VOLUME (litres); CONTAINS NO BILE (obstruction pre-ampullary); may contain food eaten DAYS AGO; RELIEF of pain by vomiting (benign PUD-GOO)'],
    ['Abdominal distension / fullness','Visible distension in epigastrium; bloating; early satiety'],
    ['Epigastric pain','History of PUD (benign); progressive pain (malignant); character change warns of malignant transformation'],
    ['Weight loss','Significant; inability to eat + catabolism + malnutrition; most dramatic in malignancy'],
    ['Anorexia','Especially malignancy'],
    ['Thirst','Dehydration'],
])
doc.add_paragraph()
ah('Signs', level=2, color=(0x2E,0x75,0xB6))
at(['Sign','Mechanism / Technique'],
[
    ['VISIBLE GASTRIC PERISTALSIS','Waves of peristalsis seen across epigastrium (LEFT → RIGHT direction); indicates dilated hypertrophied stomach trying to overcome obstruction — CLASSIC SIGN of benign pyloric stenosis'],
    ['SUCCUSSION SPLASH','Splashing sound on shaking patient\'s abdomen (or with stethoscope) ≥2 hours after last drink; indicates >300-400 mL retained gastric fluid'],
    ['Epigastric fullness / mass','Grossly dilated stomach palpable as dull, tympanic epigastric mass'],
    ['Signs of dehydration','Dry mucous membranes; reduced skin turgor; sunken eyes; tachycardia; postural hypotension'],
    ['TETANY','Hypocalcaemia from alkalosis; TROUSSEAU\'S SIGN (carpal spasm on arm cuff inflation) + CHVOSTEK\'S SIGN (facial twitch on tapping facial nerve)'],
    ['Nutritional wasting','Emaciation, temporal wasting, loose skin folds — especially malignancy'],
    ['Virchow\'s node','Left supraclavicular lymphadenopathy — gastric malignancy (Troisier\'s sign)'],
])
doc.add_paragraph()

# SECTION 6 INVESTIGATIONS
ah('6. INVESTIGATIONS', level=1)
ah('To Confirm GOO', level=2, color=(0x2E,0x75,0xB6))
at(['Investigation','Findings / Role'],
[
    ['NGT ASPIRATION (first step)','Aspirate >200-400 mL undigested food/fluid from fasting patient → confirms gastric stasis'],
    ['SALINE LOAD TEST','Instil 750 mL 0.9% saline via NGT; aspirate after 30 min. >400 mL aspirated = significant mechanical obstruction. <200 mL = resolving/no significant obstruction. Source: Yamada\'s Gastroenterology 7th Ed., p. 882'],
    ['Plain X-ray abdomen (erect + supine)','Hugely dilated stomach; air-fluid levels; absent distal bowel gas if complete obstruction; "double bubble" (duodenal atresia in neonates)'],
    ['BARIUM MEAL / Upper GI contrast study','Dilated, atonic stomach; retained barium; "rat-tail" / "bird-beak" narrowing at pylorus (malignant); smooth tapering (benign/scar); String sign (HPS); gastric emptying at 4 hours'],
    ['UPPER GI ENDOSCOPY (GOLD STANDARD)','Direct visualisation; gastric distension + food residue; biopsy of obstructing lesion (rules out malignancy); therapeutic: balloon dilation for benign strictures; stent for malignant GOO. Yamada\'s p. 882: NGT decompression before endoscopy often required.'],
    ['CT ABDOMEN + PELVIS (contrast)','Malignant GOO staging: identifies tumour, nodes, liver mets; vascular involvement; level of obstruction; guides resectability assessment'],
    ['Endoscopic Ultrasound (EUS)','T-staging gastric/duodenal cancer; deeper biopsies for submucosal lesions; TB diagnosis'],
    ['Gastric emptying scintigraphy','Differentiates mechanical from FUNCTIONAL GOO (gastroparesis — diabetic, post-vagotomy)'],
])
doc.add_paragraph()
ah('Metabolic Investigations', level=2, color=(0x2E,0x75,0xB6))
at(['Test','Expected Finding'],
[
    ['Serum electrolytes','↓ Na⁺, ↓ K⁺, ↓ Cl⁻'],
    ['Arterial Blood Gas (ABG)','Metabolic alkalosis: pH >7.45, HCO₃⁻ elevated, PCO₂ elevated (respiratory compensation)'],
    ['Blood urea + creatinine','Elevated (pre-renal uraemia)'],
    ['Serum albumin','Low (malnutrition, chronic disease)'],
    ['FBC','Anaemia (chronic disease/blood loss); leukocytosis'],
    ['Serum calcium','Ionised Ca²⁺ low (alkalosis); total may be normal'],
    ['Urinalysis','PARADOXICAL ACIDURIA: acidic pH <5 despite systemic alkalosis = severe depletion; low urinary Cl⁻ (<20 mEq/L)'],
    ['H. pylori testing','CLO test (biopsy), urea breath test, serology'],
    ['Tumour markers','CA 19-9, CEA (pancreatic/gastric); CA 72-4 (gastric)'],
])
doc.add_paragraph()

# SECTION 7 CORRECTION
ah('7. CORRECTION OF METABOLIC ABNORMALITIES (PRE-OPERATIVE RESUSCITATION)', level=1)
ap('THIS IS A CORE SUB-QUESTION — always write step-by-step. 4-5 marks are allocated here.', bold=True, color=(0xC0,0x00,0x00))
at(['Step','Action / Detail'],
[
    ['1. IV ACCESS + FLUID RESUSCITATION','Large-bore IV cannula ×2. FLUID OF CHOICE: 0.9% NORMAL SALINE (NaCl) — replaces Na⁺ + Cl⁻ deficit, corrects dehydration. DO NOT use lactated Ringer\'s (contains HCO₃⁻ precursor → worsens alkalosis). Guide volume by clinical status + CVP (target 8-12 cmH₂O) + hourly urine output.'],
    ['2. POTASSIUM REPLACEMENT (critical)','Add KCl 20-40 mEq per litre once urine output confirmed. IV KCl max 40 mEq/hour via central line + cardiac monitoring. Hypokalaemia perpetuates alkalosis — MUST correct K⁺ before alkalosis fully resolves. Target K⁺ >3.5 mEq/L before surgery.'],
    ['3. ALKALOSIS CORRECTION','Resolves automatically with Cl⁻ + K⁺ replacement. NaCl replaces Cl⁻ → kidneys excrete HCO₃⁻. Rarely need ammonium chloride (NH₄Cl) or HCl infusion (only if pH >7.60).'],
    ['4. NGT DECOMPRESSION','Large-bore NGT (16-18 Fr) free drainage + regular warm water lavage. Removes retained food/fluid. NPO. Reduces aspiration risk. Prepares stomach for endoscopy/surgery.'],
    ['5. NUTRITIONAL SUPPORT','TPN via central line if surgery delayed >5-7 days. Nasojejunal tube (NJT) feeding placed endoscopically past obstruction — preferred if possible. Correct albumin + nutritional parameters pre-op.'],
    ['6. ACID SUPPRESSION','IV Proton Pump Inhibitor: Omeprazole 40 mg IV BD or Pantoprazole. Reduces gastric secretion volume → reduces ongoing fluid/electrolyte losses.'],
    ['7. H. PYLORI ERADICATION','Triple therapy (PPI + Clarithromycin + Amoxicillin × 14 days) once patient stable — reduces acid secretion + promotes healing if benign GOO.'],
    ['8. MONITORING','Hourly urine output (catheterise) — target >0.5 mL/kg/hour. Serial electrolytes every 6-12 hours. CVP monitoring. Serial saline load testing for response.'],
])
doc.add_paragraph()
ap('PRE-OPERATIVE FITNESS CRITERIA (before surgery can proceed):', bold=True, color=(0x1F,0x4E,0x79))
criteria=['Serum K⁺ >3.5 mEq/L',
'Serum Cl⁻ >95 mEq/L',
'Urine output >1000 mL/day (>0.5 mL/kg/hr)',
'Urine Cl⁻ >20 mEq/L (marker of adequate renal perfusion + Na⁺ repletion)',
'Blood urea normalising',
'Serum albumin >30 g/L',
'Paradoxical aciduria RESOLVED (urine alkaline)',
]
for c in criteria: ab(c, bold=False)
doc.add_paragraph()

# SECTION 8 MANAGEMENT
ah('8. MANAGEMENT', level=1)

ah('A. Conservative / Medical Management', level=2, color=(0x2E,0x75,0xB6))
ap('Indications: Benign GOO (inflammatory/oedematous component — likely to respond); initial stabilisation before intervention', bold=False)
at(['Treatment','Detail'],
[
    ['NGT decompression','Large-bore NGT; free drainage + hourly warm water lavage; continue until residuals <200 mL/30 min'],
    ['IV PPI','Omeprazole 40 mg IV BD or pantoprazole — reduces acid secretion volume'],
    ['H. pylori eradication','Triple therapy: PPI + Clarithromycin + Amoxicillin × 14 days (if H. pylori +ve)'],
    ['NSAID cessation','Mandatory'],
    ['Nutritional support','TPN or nasojejunal tube feeding'],
    ['Serial saline load testing','Monitors response — <200 mL aspirate at 30 min = improving; >400 mL = persistent obstruction'],
])
ap('Response: 50-70% of benign inflammatory GOO responds within 2-3 weeks. No improvement → endoscopic or surgical intervention.', bold=True)
doc.add_paragraph()

ah('B. Endoscopic Management', level=2, color=(0x2E,0x75,0xB6))
at(['Technique','Indication','Success Rate'],
[
    ['ENDOSCOPIC BALLOON DILATION (EBD)','Benign GOO (peptic ulcer scar, anastomotic stricture); short fibrous strictures. TTS balloon dilated to 10-15 mm progressively. Require NGT decompression first.','70-85% short-term; 50-60% long-term; may need repeat sessions. Perforation risk: 1-3%'],
    ['SELF-EXPANDING METAL STENT (SEMS)','MALIGNANT GOO where surgery not feasible (metastatic disease, poor performance status). Technical success >90%.','Clinical success 80-85%; Complications: migration, tumour ingrowth, occlusion'],
    ['EUS-GUIDED GASTROENTEROSTOMY (EUS-GE) with LAMS','Novel technique; lumen-apposing metal stent creates US-guided gastrojejunostomy without surgery; high-risk patients; MOST RECENT ADVANCE','Emerging data: 90%+ technical success; avoids surgery entirely'],
])
doc.add_paragraph()

ah('C. Surgical Management', level=2, color=(0x2E,0x75,0xB6))
ap('Indications: Failed medical/endoscopic treatment; benign fibrotic scar; malignant GOO amenable to curative resection; complications (perforation, haemorrhage); diagnostic uncertainty.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ap('1. DRAINAGE PROCEDURES:', bold=True, color=(0x1F,0x4E,0x79))
at(['Procedure','Description','Indication','Advantage / Disadvantage'],
[
    ['GASTROJEJUNOSTOMY (GJJ)\n(MOST COMMON for benign GOO)','Anastomosis between posterior gastric wall and proximal jejunum. RETROCOLIC posterior GJJ preferred (short route, non-kinking). Combined with TRUNCAL VAGOTOMY to reduce acid + prevent stomal ulcer.','Benign PUD-GOO; palliative bypass for malignant GOO','Simple; bypasses obstruction. Does not remove diseased pylorus — risk of leaving occult carcinoma.'],
    ['PYLOROPLASTY: Heineke-Mikulicz','Longitudinal incision across pylorus → closed transversely (widens canal). Requires pliable tissue.','Benign GOO with soft, pliable pylorus','Combined with truncal vagotomy. Cannot do if rigid fibrotic scar.'],
    ['PYLOROPLASTY: Finney','Side-to-side gastroduodenostomy for longer duodenal strictures','Long pyloric / duodenal stricture','More extensive than H-M'],
    ['PYLOROPLASTY: Jaboulay','Gastroduodenostomy side-to-side WITHOUT opening pylorus','When pyloric canal too scarred to open safely','Avoids entering scarred pylorus'],
    ['PYLOROMYOTOMY (Ramstedt)','Longitudinal incision through hypertrophied pyloric muscle to mucosa; mucosa NOT opened','HYPERTROPHIC PYLORIC STENOSIS (infants)','Cure rate ~100%; now done laparoscopically'],
])
doc.add_paragraph()

ap('2. GASTRIC RESECTION:', bold=True, color=(0x1F,0x4E,0x79))
at(['Procedure','Description','Indication'],
[
    ['ANTRECTOMY + BILLROTH II (Gastrojejunostomy)','Resects antrum (removes gastrin source + obstructing lesion) + Roux-en-Y or loop gastrojejunostomy. Combined with truncal vagotomy.','Antral/prepyloric ulcer with GOO; if malignancy suspected'],
    ['SUBTOTAL GASTRECTOMY','Resects 75-80% of stomach + D2 lymphadenectomy + Roux-en-Y gastrojejunostomy','Malignant GOO (gastric carcinoma) — curative intent'],
    ['TOTAL GASTRECTOMY + D2','Complete stomach removal + D2 nodes + oesophagojejunostomy (Roux-en-Y)','Proximal/diffuse gastric carcinoma with GOO'],
    ['PALLIATIVE GASTROJEJUNOSTOMY','Bypass only; no resection; laparoscopic preferred','Malignant GOO — unresectable gastric carcinoma, pancreatic head carcinoma, poor operative risk; expected survival >3 months'],
])
doc.add_paragraph()

ap('3. VAGOTOMY — TYPES (HIGH YIELD TABLE):', bold=True, color=(0xC0,0x00,0x00))
at(['Type','Division','Drainage Needed?','Acid Reduction','Recurrence','Side Effects'],
[
    ['TRUNCAL VAGOTOMY','Both vagal trunks above hepatic + coeliac branches','YES (vagotomy causes gastric atony — needs pyloroplasty or GJJ)','75-80%','10-15%','Diarrhoea (20-30%), dumping, biliary dysmotility'],
    ['SELECTIVE VAGOTOMY','Complete gastric branches below hepatic + coeliac branches','YES','70-75%','10-15%','Fewer systemic effects than truncal'],
    ['HIGHLY SELECTIVE VAGOTOMY (HSV)\n= Parietal cell vagotomy\n= Proximal gastric vagotomy','Vagal branches to parietal cell mass only; PRESERVES ANTRAL BRANCHES ("crow\'s foot")','NO (antral motility intact — pylorus functions normally)','65-70%','15-20% (HIGHEST)','Lowest morbidity; best QoL; technically demanding'],
])
ap("Anterior + Posterior Nerve of Latarjet: described in Fischer's Mastery 8th Ed., p. 2906. The crow's foot branches at the angulus incisura = LIMIT OF HSV", italic=True, color=(0x70,0x70,0x70), size=9)
doc.add_paragraph()

ah('D. Malignant GOO — Specific Management', level=2, color=(0x2E,0x75,0xB6))
at(['Situation','Management'],
[
    ['Gastric carcinoma — RESECTABLE','Neoadjuvant FLOT chemotherapy (5-FU + Leucovorin + Oxaliplatin + Docetaxel; FLOT4 trial) → Subtotal/total gastrectomy + D2 lymphadenectomy → adjuvant FLOT'],
    ['Gastric carcinoma — UNRESECTABLE','SEMS stenting (if survival <3 months) OR palliative laparoscopic GJJ (if survival >3 months). Systemic chemotherapy (XELOX, FOLFOX) + anti-PD-1 (pembrolizumab/nivolumab, KEYNOTE-590, CheckMate 649)'],
    ['Pancreatic head carcinoma — RESECTABLE','Whipple\'s pancreaticoduodenectomy (pancreatic head + D2 + bile duct)'],
    ['Pancreatic head carcinoma — UNRESECTABLE','SEMS or surgical GJJ (palliative). Biliary stent for jaundice. Gemcitabine + nab-paclitaxel or FOLFIRINOX.'],
    ['Gastric lymphoma','Chemotherapy (CHOP/R-CHOP) ± H. pylori eradication; surgery only for complications'],
])
doc.add_paragraph()

# SECTION 9 COMPLICATIONS
ah('9. COMPLICATIONS', level=1)
ah('Post-Surgical Complications', level=2, color=(0x2E,0x75,0xB6))
at(['Complication','Time','Notes'],
[
    ['Anastomotic leak','Day 4-7','More common with malnutrition; CT-guided drain or re-operation'],
    ['STOMAL ULCERATION (peptic jejunal ulcer)','Weeks-months','Incomplete vagotomy or H. pylori not eradicated; Zollinger-Ellison must be excluded; treat with high-dose PPI'],
    ['DUMPING SYNDROME','Early post-op','Early (20-30 min post meal): osmotic fluid shift into lumen; Late (2-3 hrs): reactive hypoglycaemia. Small frequent meals, lie down post-meal.'],
    ['ALKALINE (BILE) REFLUX GASTRITIS','Months','Bile in gastric remnant; epigastric pain + vomiting; Roux-en-Y conversion (diverts bile away from stomach)'],
    ['AFFERENT / BLIND LOOP SYNDROME','Months','Efferent loop obstruction or kinking; bile/pancreatic secretion reflux; bilious vomiting; re-operation'],
    ['DIARRHOEA','Ongoing','Post-truncal vagotomy (20-30%); cholestyramine + dietary management'],
    ['NUTRITIONAL DEFICIENCY','Long-term','Iron deficiency (achlorhydria reduces Fe²⁺ absorption); B12 deficiency (no intrinsic factor after gastrectomy); folate deficiency; metabolic bone disease'],
])
doc.add_paragraph()

# SECTION 10 HPS
ah('10. HYPERTROPHIC PYLORIC STENOSIS (HPS) — Short Note', level=1)
at(['Feature','Detail'],
[
    ['Definition','Hypertrophy + hyperplasia of pyloric CIRCULAR MUSCLE → narrow elongated pyloric canal. Most common surgical cause of vomiting in neonates.'],
    ['Epidemiology','Male:Female = 4-5:1; first-born males; onset 3-6 weeks after birth; familial tendency; incidence 1-4/1000 births'],
    ['Presentation','Projectile, NON-BILIOUS (obstruction above ampulla) vomiting after feeds; hungry but malnourished infant; Hypochloraemic hypokalaemic metabolic alkalosis (same as adult GOO)'],
    ['Examination','PALPABLE PYLORIC MASS ("olive-shaped tumour") in RIGHT HYPOCHONDRIUM during feed + gastric peristalsis'],
    ['Imaging / Diagnosis','ULTRASOUND (gold standard): pyloric muscle thickness >4 mm + canal length >16 mm. Barium meal: "String sign" / "Caterpillar sign" / "Shouldering sign".'],
    ['Management: STEP 1','Correct metabolic abnormalities FIRST (same resuscitation as adult GOO — 0.9% NaCl + KCl). NEVER operate in biochemical crisis.'],
    ['Management: STEP 2','RAMSTEDT\'S PYLOROMYOTOMY (Fredet-Ramstedt, 1912): Longitudinal incision through hypertrophied pyloric muscle down to mucosa; MUCOSA NOT OPENED. Herniation of mucosa confirms complete myotomy. Laparoscopic preferred. Cure rate ~100%.'],
])
doc.add_paragraph()

# SECTION 11 RECENT ADVANCES
ah('11. RECENT ADVANCES', level=1)
advances=[
    'EUS-GUIDED GASTROENTEROSTOMY (EUS-GE) with LAMS (lumen-apposing metal stent) — novel US-guided GJJ creation without surgery; excellent for high-risk patients; rapidly expanding indication',
    'LAPAROSCOPIC GASTROJEJUNOSTOMY — preferred palliative procedure for malignant GOO with longer life expectancy (>3 months); equivalent to SEMS; fewer re-interventions',
    'FLOT PROTOCOL (5-FU + Leucovorin + Oxaliplatin + Docetaxel): FLOT4 trial — superior pCR and OS vs ECF for resectable gastric/GEJ adenocarcinoma; now standard perioperative chemotherapy',
    'IMMUNOTHERAPY for advanced gastric cancer: Nivolumab + chemotherapy (CheckMate 649) and Pembrolizumab + chemotherapy (KEYNOTE-590) — first-line for HER2-negative advanced gastric cancer',
    'TRASTUZUMAB (HER2-targeted): HER2+ gastric cancer (ToGA trial); add to cisplatin + 5-FU for HER2-positive tumours',
    'ROBOT-ASSISTED GASTRECTOMY — D2 lymphadenectomy with robotic precision; reduced blood loss; shorter learning curve for complex dissection',
    'PPI REVOLUTION: Dramatic reduction in need for elective acid-reduction surgery (truncal vagotomy); H. pylori eradication prevents recurrence — surgical GOO from PUD now rare in developed world',
    'PROKINETICS (domperidone, metoclopramide, erythromycin) — for gastroparesis (functional GOO); may reduce need for surgical intervention',
]
for a in advances: ab(a)
doc.add_paragraph()

# SCORING GUIDE
ah("12. EXAMINER'S SCORING GUIDE — 30 Marks", level=1)
at(['Section','Expected Marks'],
[
    ['Anatomy of stomach + pylorus (diagram + parts + blood supply + vagal nerve supply)','5'],
    ['Definition + causes (benign vs malignant vs congenital — full table)','3'],
    ['Pathophysiology — sequence of events','2'],
    ['Metabolic consequences — COMPLETE TABLE (all electrolytes + pH + paradoxical aciduria)','4'],
    ['Clinical features (succussion splash, projectile vomiting, visible peristalsis)','3'],
    ['Investigations (saline load test + endoscopy + CT + metabolic bloods)','3'],
    ['Correction of metabolic abnormalities (step-by-step — pre-op criteria)','4'],
    ['Surgical management (drainage + vagotomy types + HPS — Ramstedt)','5'],
    ['Recent advances','1'],
    ['TOTAL','30'],
])
doc.add_paragraph()

ah('Sharp-Edge Discriminators — Mark-Winners', level=2, color=(0x2E,0x75,0xB6))
tips=[
    'Vomit has NO BILE — obstruction is PRE-AMPULLARY (above ampulla of Vater)',
    'Saline Load Test: >400 mL at 30 min = mechanical obstruction; <200 mL = resolving. Source: Yamada\'s 7th Ed. p. 882',
    'PARADOXICAL ACIDURIA (Fink Phenomenon) = acidic urine despite alkalosis; signals SEVERE Na⁺ + volume depletion; pathognomonic of advanced GOO depletion',
    'DO NOT give Lactated Ringer\'s (contains HCO₃⁻ precursor → worsens alkalosis); USE 0.9% NORMAL SALINE',
    'Pre-op criteria before surgery: K⁺ >3.5, Cl⁻ >95, urine output >1000 mL/day, urine Cl⁻ >20 mEq/L',
    'Heineke-Mikulicz pyloroplasty = longitudinal incision → transverse closure',
    'HSV = NO drainage procedure needed (preserves crow\'s foot antral innervation = normal pyloric function)',
    'Ramstedt pyloromyotomy (HPS): Fredet-Ramstedt 1912; muscle split to mucosa; MUCOSA NOT OPENED',
    'PUD now causes only 5% of GOO in developed world; malignancy = 50-80%; in India PUD = 50-60% (Yamada\'s p. 1041)',
    'EUS-guided gastroenterostomy (EUS-GE) with LAMS — newest minimally invasive GOO treatment',
    'Stomal ulcer post-GJJ = incomplete vagotomy until proven otherwise → check Zollinger-Ellison',
    'Visceral afferent of Latarjet branches = "crow\'s foot" at angulus incisura = LIMIT OF HSV (Fischer\'s Mastery p. 2906)',
    'FLOT4 trial: FLOT perioperative chemotherapy superior to ECF for resectable gastric carcinoma with GOO',
]
for t in tips: ab(t)
doc.add_paragraph()
ps=doc.add_paragraph()
rs=ps.add_run("Sources: Fischer's Mastery of Surgery 8th Ed. (p. 2905-2912) | Yamada's Textbook of Gastroenterology 7th Ed. (p. 1041-1043) | Schwartz's Principles of Surgery 11th Ed. | Sabiston Textbook of Surgery 21st Ed.")
rs.italic=True; rs.font.size=Pt(9); rs.font.color.rgb=RGBColor(0x70,0x70,0x70)

out='/tmp/workspace/ms-surgery-notes/GOO_30marks.docx'
doc.save(out)
print(f'Saved: {out}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()
sec = doc.sections[0]
sec.top_margin = Cm(2); sec.bottom_margin = Cm(2)
sec.left_margin = Cm(2.5); sec.right_margin = Cm(2.5)
doc.styles['Normal'].font.name = 'Arial'
doc.styles['Normal'].font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def ah(text, level=1, color=(0x1F,0x4E,0x79)):
    p = doc.add_heading(text, level=level)
    for r in p.runs: r.font.color.rgb = RGBColor(*color)
    return p

def ap(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    r = p.add_run(text); r.bold=bold; r.italic=italic; r.font.size=Pt(size)
    if color: r.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def ab(text, bold=False):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    r = p.add_run(text); r.font.size=Pt(11); r.bold=bold
    return p

def scbg(cell, hx):
    tc=cell._tc; tcPr=tc.get_or_add_tcPr()
    shd=OxmlElement('w:shd')
    shd.set(qn('w:val'),'clear'); shd.set(qn('w:color'),'auto')
    shd.set(qn('w:fill'),hx); tcPr.append(shd)

def at(headers, rows, hc='1F4E79', arc='D6E4F0'):
    tbl=doc.add_table(rows=1+len(rows), cols=len(headers))
    tbl.style='Table Grid'
    hr=tbl.rows[0].cells
    for i,h in enumerate(headers):
        hr[i].text=h; scbg(hr[i],hc)
        for p in hr[i].paragraphs:
            for r in p.runs:
                r.bold=True; r.font.size=Pt(10); r.font.color.rgb=RGBColor(0xFF,0xFF,0xFF)
    for ri,rd in enumerate(rows):
        cs=tbl.rows[ri+1].cells
        for ci,txt in enumerate(rd):
            cs[ci].text=txt
            for p in cs[ci].paragraphs:
                for r in p.runs: r.font.size=Pt(10)
        if ri%2==0:
            for c in cs: scbg(c,arc)
    return tbl

def embed_img(url, path, w=Inches(5.5), cap=None):
    try:
        r=requests.get(url,timeout=15)
        if r.status_code==200:
            with open(path,'wb') as f: f.write(r.content)
            doc.add_picture(path,width=w)
            doc.paragraphs[-1].alignment=WD_ALIGN_PARAGRAPH.CENTER
            if cap:
                c=doc.add_paragraph(cap); c.alignment=WD_ALIGN_PARAGRAPH.CENTER
                c.runs[0].italic=True; c.runs[0].font.size=Pt(9)
    except:
        ap(f'[Image: {cap}]',italic=True,color=(0x70,0x70,0x70))

# ─────────────────── COVER ───────────────────
p=doc.add_paragraph(); p.alignment=WD_ALIGN_PARAGRAPH.CENTER
r=p.add_run('MS GENERAL SURGERY — EXAM NOTES')
r.bold=True; r.font.size=Pt(18); r.font.color.rgb=RGBColor(0x1F,0x4E,0x79)
p2=doc.add_paragraph(); p2.alignment=WD_ALIGN_PARAGRAPH.CENTER
r2=p2.add_run('Portal Hypertension — 30-Mark Question')
r2.bold=True; r2.font.size=Pt(14); r2.font.color.rgb=RGBColor(0x2E,0x75,0xB6)
p3=doc.add_paragraph(); p3.alignment=WD_ALIGN_PARAGRAPH.CENTER
r3=p3.add_run("Sources: Bailey & Love 28th Ed. | Yamada's Gastroenterology 7th Ed. | Sabiston 21st Ed. | Fischer's Mastery 8th Ed. | Schwartz's 11th Ed.")
r3.italic=True; r3.font.size=Pt(10); r3.font.color.rgb=RGBColor(0x70,0x70,0x70)
doc.add_paragraph()
pq=doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Define Portal Hypertension. Describe its anatomy, aetiology, pathophysiology, clinical features, investigations and management including treatment of oesophageal varices and ascites."   [30 Marks]').bold=True
pq.runs[0].font.size=Pt(11); pq.runs[0].font.color.rgb=RGBColor(0x7B,0x22,0x00)
doc.add_paragraph()

# image: varices CT + endoscopy
embed_img(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_9eb3974b230c2795ab0911c3c07c51012437399efbb2b40dbf1bc4b12df586b4.jpg',
    '/tmp/workspace/ms-surgery-notes/varices_ct.jpg', w=Inches(5.5),
    cap='Figure 1: Portal hypertension — Endoscopy (e) shows prominent oesophageal varices; CT-MIP and Volume Rendering (c,d,g,h,k,l) visualise portal venous collaterals including gastric varices (arrows), tortuous paraumbilical vein, and paraesophageal collaterals. (PMC / Yamada\'s 7th Ed.)'
)
doc.add_paragraph()

# ─────────────────── SECTION 1: ANATOMY ───────────────────
ah('1. ANATOMY OF THE PORTAL VENOUS SYSTEM', level=1)
ap('EXAM TIP: Always draw the portal vein and its tributaries — scores 3-4 marks.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Portal Vein — Formation, Course, Tributaries', level=2, color=(0x2E,0x75,0xB6))
at(['Feature','Detail'],
[
    ['FORMATION','Superior mesenteric vein (SMV) + Splenic vein join BEHIND THE NECK OF THE PANCREAS at the level of L1/L2 to form the portal vein'],
    ['LENGTH / DIAMETER','8 cm long; diameter 1-2 cm (>13 mm on Doppler = dilated = portal hypertension)'],
    ['COURSE','Runs in the FREE EDGE OF LESSER OMENTUM (hepatoduodenal ligament) POSTERIOR to bile duct and hepatic artery; enters porta hepatis; divides into right and left branches'],
    ['PRESSURE (normal)','5-10 mmHg (mean ~7 mmHg); HVPG (hepatic venous pressure gradient) = 3-5 mmHg'],
    ['TRIBUTARIES','Splenic vein (with inferior mesenteric vein [IMV] joining splenic vein or SMV junction); Left gastric (coronary) vein; Right gastric vein; Cystic vein; Paraumbilical veins; Right gastroepiploic vein'],
])
doc.add_paragraph()

ah('Key Tributaries', level=2, color=(0x2E,0x75,0xB6))
at(['Tributary','Drainage Territory','Clinical Importance in Portal HTN'],
[
    ['Superior Mesenteric Vein (SMV)','Small bowel, colon to mid-transverse, pancreatic head','Thrombosis = prehepatic portal HTN; Whipple resection may require SMV reconstruction'],
    ['Splenic Vein','Spleen; joins IMV + short gastric veins','Thrombosis = sinistral (left-sided) portal HTN — ISOLATED GASTRIC VARICES; splenomegaly; treat by splenectomy'],
    ['Inferior Mesenteric Vein (IMV)','Left colon, sigmoid, rectum','Joins splenic vein; collaterals in portal HTN → anorectal varices (not haemorrhoids)'],
    ['Left Gastric (Coronary) Vein','Cardia, lower oesophagus','MOST IMPORTANT: drains retrograde into oesophageal submucosal veins → OESOPHAGEAL VARICES in portal HTN'],
    ['Paraumbilical Veins','Remnant of fetal umbilical vein in falciform ligament','Reopen in portal HTN → dilated periumbilical veins = CAPUT MEDUSAE'],
    ['Short Gastric Veins','Gastric fundus','Join splenic vein; contribute to FUNDAL/GASTRIC VARICES'],
])
doc.add_paragraph()

ah('Portosystemic Anastomoses (HIGH YIELD — 5 sites)', level=2, color=(0x2E,0x75,0xB6))
ap('These become DILATED (varices) when portal pressure rises. Know all 5 sites.', bold=True, color=(0xC0,0x00,0x00))
at(['Site','Portal Tributary','Systemic Tributary','Result in Portal HTN','Clinical Test'],
[
    ['1. LOWER OESOPHAGUS (MOST IMPORTANT)','Left gastric (coronary) vein','Azygos vein (systemic)','OESOPHAGEAL VARICES — bleed catastrophically','Upper GI endoscopy (gold standard)'],
    ['2. ANORECTAL JUNCTION','Superior rectal vein (portal)','Middle + inferior rectal veins (systemic, pudendal)','ANORECTAL VARICES (NOT haemorrhoids)','Proctoscopy / sigmoidoscopy'],
    ['3. UMBILICUS (LIGAMENTUM TERES)','Left branch portal vein via paraumbilical veins (fetal umbilical vein)','Superior and inferior epigastric veins (systemic)','CAPUT MEDUSAE — dilated periumbilical veins radiating from umbilicus','Clinical inspection'],
    ['4. RETROPERITONEUM (VEINS OF RETZIUS)','SMV/IMV tributaries (ascending colon, duodenum)','Retroperitoneal veins (lumbar, renal, phrenic)','Bleeding risk during retroperitoneal surgery; rarely symptomatic','CT venography'],
    ['5. BARE AREA OF LIVER / DIAPHRAGM','Intrahepatic portal radicles','Phrenic veins + diaphragmatic veins','Collaterals on diaphragm; relevant at hepatic surgery','CT/intraoperative finding'],
])
doc.add_paragraph()

# ─────────────────── SECTION 2: DEFINITION + CLASSIFICATION ───────────────────
ah('2. DEFINITION', level=1)
ap('PORTAL HYPERTENSION = sustained elevation of portal venous pressure above the upper limit of normal (>5 mmHg) measured as the hepatic venous pressure gradient (HVPG).', bold=True)
doc.add_paragraph()
ab('Normal HVPG: 3-5 mmHg')
ab('Portal hypertension defined: HVPG >5 mmHg')
ab('Clinically significant portal hypertension (CSPH): HVPG ≥10 mmHg — threshold for complications (ascites, varices)')
ab('Variceal haemorrhage risk rises significantly when HVPG >12 mmHg')
ab('HVPG >20 mmHg = early rebleeding risk; high early mortality')
ab('Source: Yamada\'s Gastroenterology 7th Ed., p. 2858 — HVPG >10 correlates with higher decompensation risk', bold=True)
doc.add_paragraph()

# ─────────────────── SECTION 3: CLASSIFICATION + AETIOLOGY ───────────────────
ah('3. CLASSIFICATION AND AETIOLOGY', level=1)
ap('Classification by site of obstruction/resistance — ESSENTIAL for exam.', bold=True, color=(0xC0,0x00,0x00))
at(['Class','HVPG','Sub-type','Causes'],
[
    ['PRE-HEPATIC\n(Prehepatic)','Normal (<5 mmHg)\n[portal pressure elevated; hepatic sinusoidal pressure normal]','Portal vein / splenic vein obstruction','PORTAL VEIN THROMBOSIS (PVT) — most common prehepatic cause (neonatal umbilical sepsis, hypercoagulable states — Factor V Leiden, PNH, JAK2 mutation, cirrhosis); SPLENIC VEIN THROMBOSIS (pancreatitis, pancreatic cancer → sinistral portal HTN); Compression of portal vein by tumour/lymph node; Congenital stenosis'],
    ['INTRAHEPATIC\n(Most common overall — 90%)','Elevated (>5 mmHg)','Presinusoidal\n(normal free hepatic venous pressure)','SCHISTOSOMIASIS (most common worldwide — periportal fibrosis — eggs deposit in portal tracts; Symmers pipe-stem fibrosis); Primary Biliary Cholangitis (PBC); Primary Sclerosing Cholangitis (PSC); Congenital hepatic fibrosis; Nodular regenerative hyperplasia; Idiopathic non-cirrhotic portal HTN'],
    ['','','Sinusoidal\n(most common in developed world)','CIRRHOSIS — accounts for >90% of portal HTN in developed countries (Bailey & Love 28th Ed., Ch. 69). Causes: Alcohol (most common in West); Chronic HBV/HCV; NAFLD/NASH; Autoimmune hepatitis; Wilson\'s disease; Haemochromatosis; Alpha-1-antitrypsin deficiency'],
    ['','','Postsinusoidal','Veno-occlusive disease (VOD/SOS — sinusoidal obstruction syndrome); post-bone marrow transplant; hepatic irradiation; pyrrolizidine alkaloids (bush tea); Alcoholic hepatitis'],
    ['POST-HEPATIC\n(Posthepatic)','Normal HVPG\n[elevated hepatic venous pressure; normal hepatic sinusoidal pressure]','Hepatic vein / IVC / cardiac','BUDD-CHIARI SYNDROME (hepatic vein thrombosis — hypercoagulable states: PNH, polycythaemia vera, pregnancy, OCP, JAK2 mutation); IVC webs/thrombosis; Constrictive pericarditis; Right heart failure; Tricuspid regurgitation'],
])
doc.add_paragraph()
ap('INDIA-SPECIFIC: In India + South Asia, schistosomiasis is NOT the primary cause — EXTRAHEPATIC PORTAL VEIN OBSTRUCTION (EHPVO) in children and viral hepatitis/cirrhosis in adults are most common. Non-cirrhotic portal fibrosis (NCPF) is also a distinct entity common in India.', bold=True, color=(0x1F,0x4E,0x79))
doc.add_paragraph()

# ─────────────────── SECTION 4: PATHOPHYSIOLOGY ───────────────────
ah('4. PATHOPHYSIOLOGY', level=1)

ah('Mechanisms of Portal Hypertension', level=2, color=(0x2E,0x75,0xB6))
ab('INCREASED PORTAL RESISTANCE: Ohm\'s Law analogy: ΔP = Q × R (portal pressure = portal blood flow × portal resistance). In cirrhosis: fibrosis + regenerative nodules → increased STRUCTURAL resistance')
ab('INCREASED PORTAL BLOOD FLOW (aggravating factor): Splanchnic vasodilation (NO-mediated in cirrhosis) → increased flow → worsens portal hypertension even if resistance partially treated')
ab('VASOACTIVE MEDIATORS: Decreased hepatic NO → intrahepatic vasoconstriction; Increased systemic NO (endothelin, substance P) → splanchnic vasodilation; Bacterial translocation (gut → mesenteric nodes) → systemic inflammation → hyperdynamic circulation')
doc.add_paragraph()

ah('Consequences — Portosystemic Collateral Formation', level=2, color=(0x2E,0x75,0xB6))
at(['Consequence','Mechanism','Clinical Result'],
[
    ['PORTOSYSTEMIC COLLATERALS','Elevated portal pressure → pre-existing anastomoses dilate; portal blood bypasses liver','Oesophageal/gastric/anorectal varices; caput medusae; collateral vessels on CT'],
    ['ASCITES','Portal hypertension → increased sinusoidal pressure → lymph formation exceeds thoracic duct capacity → leaks into peritoneum; hypoalbuminaemia (↓ oncotic pressure); secondary hyperaldosteronism → Na+/H₂O retention; RAAS activation (reduced effective arterial blood volume)','Abdominal distension; shifting dullness; fluid thrill; SBP risk'],
    ['SPLENOMEGALY + HYPERSPLENISM','Increased splenic venous backpressure → splenomegaly → sequestration of blood cells','Thrombocytopenia (bleeding risk); Leucopenia (infection risk); Anaemia'],
    ['HEPATIC ENCEPHALOPATHY (HE)','Portosystemic shunting → ammonia + false neurotransmitters + mercaptans bypass liver → reach brain; GABA-ergic system activation; astrocyte swelling','Confusion, asterixis, flap, coma (Grade I-IV)'],
    ['HEPATORENAL SYNDROME (HRS)','Splanchnic vasodilation → reduced effective circulating volume → intense renal vasoconstriction (renal hypoperfusion) → renal failure despite normal kidneys','HRS type 1 (acute) and type 2 (chronic); poor prognosis'],
    ['HEPATOPULMONARY SYNDROME (HPS)','Intrapulmonary vasodilation (NO-mediated) → V/Q mismatch → hypoxaemia','Dyspnoea, clubbing, cyanosis; paradoxical improvement lying down (orthodeoxia/platypnoea)'],
    ['PORTAL HYPERTENSIVE GASTROPATHY','Mucosal congestion of gastric body + fundus; dilated submucosal vessels; "snakeskin/mosaic" appearance on endoscopy','Chronic blood loss → iron deficiency anaemia; rarely acute haemorrhage'],
    ['HYPERDYNAMIC CIRCULATION','Splanchnic vasodilation + increased cardiac output; reduced SVR; tachycardia','Bounding pulse; wide pulse pressure; reduced renal perfusion → AKI risk'],
])
doc.add_paragraph()

# ─────────────────── SECTION 5: CLINICAL FEATURES ───────────────────
ah('5. CLINICAL FEATURES', level=1)
ah('Symptoms', level=2, color=(0x2E,0x75,0xB6))
at(['Symptom','Detail'],
[
    ['HAEMATEMESIS','Sudden, large-volume, life-threatening upper GI bleed from ruptured oesophageal/gastric varices — COMMONEST CAUSE OF DEATH in portal HTN; 30-50% mortality per bleed episode'],
    ['Abdominal distension','Ascites — progressive; worse in evening; associated fullness, discomfort, dyspnoea when massive'],
    ['Jaundice','Hepatocellular failure; acholuric jaundice (conjugated); Charcot\'s triad if secondary biliary obstruction'],
    ['Abdominal pain (RUQ)','Hepatic capsule stretching; cholangitis; hepatoma development'],
    ['Ankle oedema','Hypoalbuminaemia + secondary hyperaldosteronism'],
    ['Oliguria','Hepatorenal syndrome; acute kidney injury from variceal bleed'],
    ['Altered consciousness','Hepatic encephalopathy — precipitated by infection, GI bleed, constipation, sedatives'],
    ['Weight loss, wasting','Hepatic failure → protein catabolism; reduced appetite'],
    ['Easy bruising / bleeding tendency','Coagulopathy (reduced clotting factor synthesis by liver) + thrombocytopenia'],
    ['Dyspnoea','Hepatic hydrothorax; hepatopulmonary syndrome; ascites-related elevation of diaphragm'],
])
doc.add_paragraph()

ah('Signs', level=2, color=(0x2E,0x75,0xB6))
at(['Sign','Mechanism / Significance'],
[
    ['SPLENOMEGALY','Splenic vein backpressure; enlarged firm spleen in left hypochondrium; may be massive; associated hypersplenism'],
    ['ASCITES','Shifting dullness (>500 mL); fluid thrill (massive ascites); everted umbilicus'],
    ['CAPUT MEDUSAE','Dilated periumbilical veins (paraumbilical veins open); veins radiate from umbilicus (portal → systemic); flow AWAY from umbilicus (unlike IVC obstruction where flow is upward)'],
    ['SPIDER NAEVI','Dilated arterioles with radiating legs; blanch on pressure; >5 = significant; on drainage territory of SVC (face, chest, arms)'],
    ['PALMAR ERYTHEMA','Reddening of thenar + hypothenar eminences; hyperdynamic circulation'],
    ['LIVER — CIRRHOTIC','Shrunken, irregular, hard liver; right lobe atrophy + left lobe hypertrophy; hepatomegaly (early) or small liver (late cirrhosis)'],
    ['JAUNDICE + SCLERAL ICTERUS','Hepatocellular dysfunction; conjugated hyperbilirubinaemia'],
    ['DUPUYTREN\'S CONTRACTURE','Fibrous proliferation (palmar fascia) — associated with alcohol/cirrhosis'],
    ['PAROTID ENLARGEMENT','Bilateral parotid hypertrophy in alcoholic liver disease'],
    ['GYNAECOMASTIA + TESTICULAR ATROPHY','Altered sex hormone metabolism (reduced oestrogen clearance) — in males'],
    ['ASTERIXIS ("LIVER FLAP")','Negative myoclonus — hands extended; rapid flexion-extension; HEPATIC ENCEPHALOPATHY'],
    ['FETOR HEPATICUS','Sweet, musty breath — dimethyl sulphide; portosystemic shunting of mercaptans'],
    ['LEUKONYCHIA (WHITE NAILS)','Hypoalbuminaemia; Muehrcke\'s lines (paired white bands)'],
    ['TERRY\'S NAILS','Proximal white, distal red — cirrhosis, cardiac failure, renal failure'],
    ['ANORECTAL VARICES','Dilated superior rectal veins; NOT haemorrhoids (haemorrhoids are dilated anal cushion vessels; portal HTN → anorectal varices)'],
    ['VIRCHOW\'S NODE','Left supraclavicular node — hepatoma or gastric malignancy causing secondary cirrhosis'],
])
doc.add_paragraph()

# ─────────────────── SECTION 6: INVESTIGATIONS ───────────────────
ah('6. INVESTIGATIONS', level=1)
ah('Blood Tests', level=2, color=(0x2E,0x75,0xB6))
at(['Test','Finding','Significance'],
[
    ['FBC','Thrombocytopenia (<100,000); Anaemia; Leucopenia','Hypersplenism; chronic blood loss; bone marrow suppression'],
    ['Liver Function Tests (LFTs)','Elevated bilirubin; ↑ ALT/AST (hepatocellular); ↑ ALP/GGT (cholestatic); ↓ albumin; prolonged PT/INR','Hepatocellular dysfunction; cholestasis; synthetic failure'],
    ['Coagulation (PT/INR)','Prolonged; INR >1.5 = significant coagulopathy','Reduced clotting factors (all except VIII); marker of hepatic synthetic function; Child-Pugh score'],
    ['Serum albumin','Low (<35 g/L)','Reduced hepatic synthesis; oncotic pressure → ascites/oedema'],
    ['Serum ammonia','Elevated','Hepatic encephalopathy; not used routinely as not reliably correlated'],
    ['Renal function (Cr, urea, electrolytes)','Elevated Cr/urea (HRS, AKI); hyponatraemia (dilutional)','Hepatorenal syndrome; electrolyte monitoring'],
    ['Serology','HBsAg, HBeAg, anti-HCV, ANA, AMA, ASMA, alpha-1-AT, ceruloplasmin, ferritin/iron studies','Aetiology of cirrhosis'],
    ['Tumour markers','AFP (hepatocellular carcinoma — surveillance in cirrhosis; >400 ng/mL = HCC)','HCC complicates 3-5%/year in cirrhosis'],
    ['Ascitic fluid analysis (diagnostic tap)','SAAG ≥1.1 g/dL = portal HTN. Cell count, protein, LDH, culture, cytology, amylase, triglycerides','SBP (PMN >250/mm³); secondary peritonitis; chylous ascites'],
])
doc.add_paragraph()

ah('SAAG (Serum-Ascites Albumin Gradient) — KEY FORMULA', level=2, color=(0x2E,0x75,0xB6))
ap('SAAG = Serum albumin − Ascites albumin', bold=True, color=(0xC0,0x00,0x00))
at(['SAAG','Interpretation','Causes'],
[
    ['≥1.1 g/dL (HIGH GRADIENT)','Portal hypertension related ascites (sinusoidal pressure elevated)','Cirrhosis; Budd-Chiari; right heart failure; hepatic vein thrombosis; IVC obstruction; massive liver metastases'],
    ['<1.1 g/dL (LOW GRADIENT)','NON-portal hypertension ascites (no elevated sinusoidal pressure)','Peritoneal carcinomatosis; TB peritonitis; nephrotic syndrome; pancreatitis; serositis'],
])
doc.add_paragraph()

ah('Imaging', level=2, color=(0x2E,0x75,0xB6))
at(['Investigation','Findings in Portal HTN'],
[
    ['ULTRASOUND DOPPLER (first-line)','Portal vein diameter >13 mm (dilated); Loss of respiratory variation in portal flow; Reversed (hepatofugal) flow in portal vein; Splenomegaly (>12 cm); Ascites; Cirrhotic liver texture; Thickened gallbladder wall; Paraumbilical vein patency'],
    ['CT ABDOMEN + CHEST (contrast — portal venous phase)','Cirrhotic liver morphology; Portal vein + varices; Splenic vein thrombosis; Splenomegaly; Ascites; Collateral vessels (oesophageal, gastric, paraumbilical, retroperitoneal); HCC (arterial enhancement + washout); Budd-Chiari (caudate lobe hypertrophy, absence of hepatic veins)'],
    ['MRI / MR Angiography','Superior soft tissue resolution; Hepatic veins + portal veins; Budd-Chiari; Non-invasive characterisation of HCC vs regenerative nodule; Magnetic resonance elastography for fibrosis staging'],
    ['Upper GI Endoscopy (GOLD STANDARD for varices)','Oesophageal varices (Grade I-IV); Red-wale markings (risk signs); Gastric varices (GOV1, GOV2, IGV1, IGV2 — Sarin classification); Portal hypertensive gastropathy (mosaic/snakeskin); Duodenal/jejunal varices'],
    ['HVPG Measurement (hepatic venous pressure gradient)','HVPG = WHVP (wedged hepatic venous pressure) − FHVP (free hepatic venous pressure). Normal: 3-5 mmHg. CSPH: ≥10 mmHg. Variceal haemorrhage threshold: >12 mmHg. Source: Yamada\'s 7th Ed., p. 2858'],
    ['Liver Biopsy (transvenous/percutaneous)','Histological staging; fibrosis scoring (METAVIR F0-F4); aetiology; transvenous preferred in coagulopathy/ascites (Yamada\'s p. 2857)'],
    ['Elastography (FibroScan)','Liver stiffness measurement (kPa); non-invasive fibrosis staging; ≥20 kPa = significant portal HTN; Yamada\'s p. 2857'],
])
doc.add_paragraph()

ah('Child-Turcotte-Pugh (CTP) Score — EXAM TABLE', level=2, color=(0x2E,0x75,0xB6))
ap('Used to assess severity of cirrhosis and predict surgical mortality. Source: Bailey & Love 28th Ed., p. 1217.', bold=False, italic=True, color=(0x70,0x70,0x70))
at(['Parameter','1 Point','2 Points','3 Points'],
[
    ['Bilirubin (μmol/L)','<34','34-50','>50'],
    ['Albumin (g/L)','>35','25-35','<25'],
    ['Ascites','None','Easily controlled','Poorly controlled'],
    ['Encephalopathy','None','Grade I or II','Grade III or IV'],
    ['INR','<1.7','1.7-2.2','>2.2'],
])
doc.add_paragraph()
at(['Class','Score','Operative Mortality (Bailey & Love p. 1217)','1-Year Survival','2-Year Survival'],
[
    ['CTP-A','5-6 points','10%','100%','85%'],
    ['CTP-B','7-9 points','30%','80%','60%'],
    ['CTP-C','10-15 points','75-80%','45%','35%'],
])
ap('MELD score = 3.78×ln(bilirubin mg/dL) + 11.2×ln(INR) + 9.57×ln(creatinine mg/dL) + 6.43. Predicts 90-day mortality. Each MELD point >20 adds 2% operative mortality. Used to prioritise liver transplant waiting lists. Source: Bailey & Love 28th Ed., p. 1217.', italic=True, color=(0x70,0x70,0x70), size=9)
doc.add_paragraph()

# ─────────────────── SECTION 7: MANAGEMENT ───────────────────
ah('7. MANAGEMENT', level=1)
ap('Management is divided by: (A) Acute variceal haemorrhage, (B) Secondary prophylaxis, (C) Primary prophylaxis, (D) Ascites, (E) Hepatic encephalopathy, (F) Surgical shunts, (G) Liver transplantation.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('A. ACUTE VARICEAL HAEMORRHAGE — EMERGENCY MANAGEMENT', level=2, color=(0x2E,0x75,0xB6))
ap('Mortality per bleed episode: 30-50%. Must act within minutes to hours.', bold=True, color=(0xC0,0x00,0x00))
at(['Phase','Action','Detail'],
[
    ['IMMEDIATE RESUSCITATION','Airway protection + O₂','Intubate if massive haemorrhage or encephalopathy — prevents aspiration'],
    ['','2 large-bore IVCs + cross-match','FBC, coagulation, LFTs, renal function, blood cultures, group and save'],
    ['','Blood transfusion — RESTRICTIVE','Target Hb 70-80 g/L (NOT >80 g/L — over-transfusion increases portal pressure and rebleeding risk). Platelets if <50,000. FFP if INR >1.5.'],
    ['','Avoid large volumes crystalloid','Worsens portal pressure; precipitates rebleeding'],
    ['VASOACTIVE DRUGS\n(Start BEFORE endoscopy — immediately on admission)','TERLIPRESSIN 2 mg IV bolus 4-6 hourly (reduces 5-day mortality — LEVEL 1A evidence)','Vasopressin V1 receptor agonist → splanchnic vasoconstriction → reduces portal pressure. Continue for 3-5 days.'],
    ['','Alternative: SOMATOSTATIN 250 μg bolus then 250 μg/hour infusion','Or OCTREOTIDE (somatostatin analogue) 50 μg bolus + 50 μg/hour for 5 days'],
    ['ANTIBIOTIC PROPHYLAXIS\n(MANDATORY)','Ceftriaxone 1 g IV daily × 5-7 days (preferred)\nOR Norfloxacin 400 mg PO BD','REDUCES EARLY REBLEEDING AND INFECTION; reduces 5-day mortality. Patients with cirrhosis have increased translocation risk. Source: Yamada\'s 7th Ed.'],
    ['HEPATIC ENCEPHALOPATHY PROPHYLAXIS','Lactulose via NGT','Prevents ammonia absorption; bowel cleansing of blood'],
    ['URGENT UPPER GI ENDOSCOPY\n(within 12 hours — GOLD STANDARD)','ENDOSCOPIC VARICEAL LIGATION (EVL/banding) — TREATMENT OF CHOICE','Rubber bands applied to varices at gastro-oesophageal junction. Superior to sclerotherapy. Aim ≤6 bands per session. Obliteration sessions every 2-4 weeks. Success 85-90%.'],
    ['','Endoscopic sclerotherapy (2nd line)','Injection of sclerosant (ethanolamine, polydocanol, STD) into varices if banding not possible. Higher complication rate (ulceration, stricture).'],
    ['REFRACTORY / FAILED ENDOSCOPY\n(5-10% cases)','SENGSTAKEN-BLAKEMORE TUBE (SBT) / Minnesota tube','Balloon tamponade; gastric balloon 300 mL air + oesophageal balloon 40 mmHg. TEMPORARY BRIDGE only (max 24 hours); risk of oesophageal necrosis/aspiration. Intubate first. Replace with TIPS within 24 hours.'],
    ['','TIPS (TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT)','HVPG target <12 mmHg after TIPS. Indicated for: failed endoscopic treatment (rescue TIPS); HVPG >20 at index bleed (early TIPS — within 72 hours); good evidence for early TIPS in high-risk CTP-B + C patients. Source: Yamada\'s 7th Ed., p. 2859'],
    ['','Covered PTFE stents (e-PTFE TIPS)','Viatorr stent — longer patency than bare stents; 80% 2-year patency vs 40% bare stent'],
])
doc.add_paragraph()

ah('B. SECONDARY PROPHYLAXIS (Prevention of Rebleeding)', level=2, color=(0x2E,0x75,0xB6))
ap('Start IMMEDIATELY after haemostasis from index bleed. Goal: prevent rebleeding (50% risk in 6 weeks without treatment).', bold=False)
at(['Treatment','Detail','Efficacy'],
[
    ['NON-SELECTIVE BETA-BLOCKERS (NSBBs)','PROPRANOLOL 40 mg BD (titrate to reduce resting HR by 25% or to 55 bpm) OR NADOLOL 40-80 mg OD OR CARVEDILOL 6.25-12.5 mg OD (also reduces hepatic vascular resistance — superior to propranolol in some studies)','Reduce portal pressure by: (a) β1 blockade → reduces cardiac output; (b) β2 blockade → splanchnic vasoconstriction. Reduces rebleeding risk by 40%. COMBINES WELL WITH EVL.'],
    ['ENDOSCOPIC VARICEAL LIGATION (EVL)','Repeat banding sessions every 2-4 weeks until variceal obliteration (usually 3-5 sessions). Then surveillance endoscopy every 6-12 months.','Superior to sclerotherapy. Combined with NSBB = BEST COMBINATION for secondary prophylaxis.'],
    ['COMBINATION NSBB + EVL','GOLD STANDARD for secondary prophylaxis','Synergistic: EVL obliterates varices; NSBB prevents new varix formation and reduces portal pressure'],
    ['TIPS (if above fails)','Reduces portal pressure to <12 mmHg; controls rebleeding in >90%. Risk: hepatic encephalopathy (25-30%). Contraindications: MELD >18-25; hepatic encephalopathy; severe pulmonary HTN. Source: Yamada\'s p. 2859','Post-TIPS encephalopathy managed with rifaximin + lactulose'],
])
doc.add_paragraph()

ah('C. PRIMARY PROPHYLAXIS (Preventing First Bleed)', level=2, color=(0x2E,0x75,0xB6))
ap('All cirrhotics should have index endoscopy. Treat medium/large varices or varices with red signs.', bold=False)
at(['Variceal Grade','Treatment'],
[
    ['Small varices, no red signs, compensated cirrhosis','NSBB (propranolol/nadolol) — reduces progression and bleeding risk; OR observation if NSBB not tolerated'],
    ['Medium/large varices (Grade II-III)','NSBB (propranolol/nadolol/carvedilol) OR EVL (equally effective)'],
    ['Any grade + red-wale markings (high-risk signs)','NSBB + EVL or EVL alone — initiate immediately'],
    ['CTP-C (decompensated)','EVL preferred over NSBB (NSBB poorly tolerated in severe liver disease; hypotension risk)'],
])
doc.add_paragraph()

ah('Variceal Grading Systems (Endoscopy)', level=2, color=(0x2E,0x75,0xB6))
at(['Grade','Appearance','Bleeding Risk'],
[
    ['Grade I','Small, straight varices; collapse on air insufflation','Low'],
    ['Grade II','Tortuous, moderate-sized varices; partially obstruct lumen; do not collapse fully','Moderate'],
    ['Grade III','Large, coil-shaped varices; meet in lumen; markedly obstruct lumen; do not collapse on insufflation','High'],
    ['Grade IV (some systems)','Very large, touching and obstructing lumen','Very High'],
    ['RED-WALE MARKS','Longitudinal red streaks on variceal surface = high-risk stigmata; fibrin plug over micro-erosion','HIGH RISK — treat regardless of size'],
])
doc.add_paragraph()

ah('D. MANAGEMENT OF ASCITES', level=2, color=(0x2E,0x75,0xB6))
at(['Step','Treatment','Detail'],
[
    ['Step 1: Mild/Moderate','SODIUM RESTRICTION + DIURETICS','Salt restriction (<88 mmol/day = 5 g NaCl/day). SPIRONOLACTONE 100-400 mg/day (aldosterone antagonist) ± FUROSEMIDE 40-160 mg/day (ratio 100:40). Monitor electrolytes + renal function.'],
    ['Step 2: Tense/refractory','LARGE VOLUME PARACENTESIS (LVP)','Drain >5 litres with simultaneous IV albumin infusion (8 g albumin per litre drained) to prevent post-paracentesis circulatory dysfunction (PPCD). Repeat as needed.'],
    ['Step 3: Refractory ascites','TIPS','Reduces sinusoidal pressure; controls ascites in 75-80%; risk HE. TIPS vs paracentesis: TIPS has better transplant-free survival at 24 months (Yamada\'s p. 2859).'],
    ['Spontaneous Bacterial Peritonitis (SBP)','Ceftriaxone 1g IV OD × 5 days (or Cefotaxime 2g IV TDS)','Diagnosis: PMN >250/mm³ in ascitic fluid. IV albumin 1.5 g/kg Day 1 + 1 g/kg Day 3 reduces HRS and mortality. Secondary prophylaxis: Norfloxacin 400 mg OD lifelong (or Trimethoprim-sulfamethoxazole 960 mg 5 days/week). Yamada\'s p. 2859.'],
    ['Hepatic hydrothorax','TIPS or serial thoracentesis','Pleural effusion from ascites transdiaphragmatic passage; usually right-sided; VATS repair of diaphragmatic defect possible'],
])
doc.add_paragraph()

ah('E. HEPATIC ENCEPHALOPATHY (HE) — MANAGEMENT', level=2, color=(0x2E,0x75,0xB6))
at(['Grade','Signs','Management'],
[
    ['Grade I','Mild confusion; sleep reversal; personality change','Identify and treat precipitants: GI bleed, infection, constipation, sedatives, electrolyte imbalance, AKI'],
    ['Grade II','Lethargy; disorientation; asterixis (liver flap)','Lactulose 30-60 mL BD-TDS (titrate to 2-3 soft stools/day); Low-protein diet ONLY if severe (caution — protein restriction worsens sarcopenia)'],
    ['Grade III','Stupor; meaningful responses to stimuli; asterixis present','ICU; airway protection; Lactulose via NGT; RIFAXIMIN 550 mg BD (non-absorbed antibiotic; reduces intestinal ammonia-producing bacteria; superior to neomycin; standard secondary prophylaxis)'],
    ['Grade IV (hepatic coma)','Unresponsive; decerebrate posturing; DEAD if no transplant','Intubation + ventilation; Liver transplant assessment; Treat reversible factors'],
])
ap('RIFAXIMIN 550 mg BD + Lactulose = GOLD STANDARD for secondary prophylaxis of HE (reduces hospitalisation by 50%).', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('F. TIPS — TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (DETAILED)', level=2, color=(0x2E,0x75,0xB6))
ap('First introduced 1989 (Richter). Creates artificial conduit between intrahepatic portal vein and hepatic vein. Source: Yamada\'s Gastroenterology 7th Ed., p. 2859.', italic=True, color=(0x70,0x70,0x70), size=9)
at(['Aspect','Detail'],
[
    ['TECHNIQUE','Jugular vein → right hepatic vein → needle puncture through liver parenchyma → portal vein → balloon dilation → PTFE-covered expandable stent placed → HVPG drops below 12 mmHg'],
    ['TARGET HVPG','<12 mmHg for variceal haemorrhage; <10 mmHg for refractory ascites (Yamada\'s p. 2859)'],
    ['INDICATIONS','Acute variceal haemorrhage (rescue or early TIPS); refractory variceal bleeding; refractory ascites; Budd-Chiari syndrome; portal hypertensive gastropathy; hepatic hydrothorax; hepatorenal/hepatopulmonary syndrome (Yamada\'s p. 2859)'],
    ['ABSOLUTE CONTRAINDICATIONS','Primary prevention of variceal bleeding; congestive heart failure; severe pulmonary HTN (mean >45 mmHg); uncontrolled sepsis; multiple hepatic cysts; severe tricuspid regurgitation'],
    ['RELATIVE CONTRAINDICATIONS','Portal/hepatic vein thrombosis; hepatic masses; thrombocytopenia <20; pre-existing HE; bilirubin >3 mg/dL; sodium ≤130; MELD >18-25 (Yamada\'s p. 2859)'],
    ['COMPLICATIONS','Hepatic encephalopathy (25-30% — most important); stent stenosis/occlusion (covered stent 80% 2yr patency; bare stent 40%); haemorrhage (capsular perforation in 33%; significant bleeding 1-2%); right heart failure; procedure mortality 0.6-4.3% (Yamada\'s p. 2859)'],
    ['OUTCOMES FOR ASCITES','TIPS vs paracentesis: tense ascites recurrence 42% vs 89%; transplant-free survival better with TIPS at 6/12/24/36 months (Yamada\'s p. 2859)'],
])
doc.add_paragraph()

ah('G. SURGICAL SHUNTS (Porto-systemic Shunt Surgery)', level=2, color=(0x2E,0x75,0xB6))
ap('Largely replaced by TIPS; now reserved for TIPS failure, TIPS contraindication, or pre-transplant scenarios. Surgical mortality correlates with CTP class.', bold=False)
at(['Shunt Type','Procedure','Key Features','Indication'],
[
    ['TOTAL PORTOCAVAL SHUNT\n(End-to-side / Side-to-side)','Portal vein → IVC direct anastomosis (end-to-side or side-to-side)','Total shunt → 100% portal decompression → hepatic encephalopathy in 40-50%; abolishes portal perfusion → liver atrophy; GOOD haemostasis. Easy to perform.','Acute emergency (end-to-side); bleeding not controlled by other means; Budd-Chiari (side-to-side)'],
    ['SELECTIVE DISTAL SPLENORENAL SHUNT\n(WARREN SHUNT — PREFERRED)','Splenic vein disconnected from portal vein + anastomosed to left renal vein (end-to-side)','SELECTIVE decompression of gastro-oesophageal varices (via short gastrics → spleen → splenic vein → renal vein) while MAINTAINING hepatopetal portal flow → preserves liver function; lower HE rate than total shunt.','Good hepatic reserve (CTP-A, CTP-B); good technique; requires patent splenic vein; favoured in non-alcoholic cirrhosis; gold standard selective shunt'],
    ['MESOCAVAL SHUNT (DRAPANAS)','SMV → IVC (interposition graft with Dacron or vein graft)','Partial shunt; decompresses portal system; preserves some hepatopetal flow; easier than splenorenal','Portal/splenic vein not suitable; obese patients'],
    ['CENTRAL SPLENORENAL SHUNT','Splenic vein (central) + left renal vein (end-to-side anastomosis) + splenectomy','Splenectomy + shunt in one operation; useful when splenomegaly + hypersplenism + varices coexist; less selective than Warren shunt','Hypersplenism + varices; splenic artery aneurysm'],
    ['SUGIURA PROCEDURE\n(Devascularisation)','Extensive oesophagogastric devascularisation + oesophageal transection + splenectomy + vagotomy (and pyloroplasty)','NO shunt; does not worsen HE; preserves hepatic blood flow; useful in patients with compromised liver function (CTP-C); popular in Japan and India (where extrahepatic PVT common and portal vein not suitable for shunt)','Prehepatic portal HTN (EHPVO); failed shunt; CTP-C where TIPS not possible; India/Japan experience'],
])
doc.add_paragraph()

ah('H. LIVER TRANSPLANTATION', level=2, color=(0x2E,0x75,0xB6))
ab('DEFINITIVE TREATMENT for end-stage liver disease with portal hypertension')
ab('Indications: CTP-C; MELD >15 (or >18 for waitlist priority); refractory ascites; spontaneous bacterial peritonitis; hepatorenal syndrome; recurrent variceal haemorrhage unresponsive to other treatment')
ab('MELD score used to allocate organs — higher MELD = greater priority')
ab('Pre-transplant TIPS may bridge to transplantation by controlling complications')
ab('Outcomes: 5-year survival 70-85% (living donor) and 60-75% (deceased donor)')
ab('Contraindications: Active alcohol/drug use (6 months sobriety required); extrahepatic malignancy; severe cardiopulmonary disease; active sepsis outside hepatobiliary system')
doc.add_paragraph()

# ─────────────────── SECTION 8: BUDD-CHIARI ───────────────────
ah('8. BUDD-CHIARI SYNDROME (BCS) — Short Note (Posthepatic Portal HTN)', level=1)
ap('Obstruction of hepatic venous outflow (hepatic veins ± IVC) → posthepatic portal hypertension.', bold=True)
at(['Feature','Detail'],
[
    ['CAUSES','Hypercoagulable states (PNH — most common association; polycythaemia vera; essential thrombocythaemia; antiphospholipid syndrome; pregnancy/OCP; JAK2 mutation); IVC webs (common in India/Asia); tumour invasion (HCC)'],
    ['PATHOLOGY','Hepatic venous obstruction → sinusoidal congestion → centrilobular necrosis → cirrhosis. CAUDATE LOBE HYPERTROPHY (caudate lobe has direct IVC drainage — spared).'],
    ['CLINICAL','Classical TRIAD: RUQ pain + Rapid-onset ascites + Hepatomegaly. Jaundice (variable). Fulminant hepatic failure in acute BCS.'],
    ['DIAGNOSIS','Doppler USS (absence of hepatic vein flow; thrombosis; caudate hypertrophy); CT venography; MRI; Hepatic venography (gold standard — "spider web" collateral pattern).'],
    ['MANAGEMENT','Anticoagulation (LMWH → warfarin / DOAC) lifelong; Treat underlying cause (JAK2 → cytoreduction; PNH → eculizumab). TIPS (hepatic vein → IVC bypass). Surgery: side-to-side portocaval shunt (decompresses liver into IVC). Liver transplantation for fulminant/chronic failure.'],
])
doc.add_paragraph()

# ─────────────────── SECTION 9: RECENT ADVANCES ───────────────────
ah('9. RECENT ADVANCES', level=1)
advances=[
    'EARLY TIPS (within 72 hours of admission for high-risk variceal bleed, CTP-B+C) — GARCIA-PAGAN trial: early TIPS reduced failure to control bleeding (failure 3% vs 50%; 1-year survival 86% vs 61%). Now standard in high-risk patients.',
    'COVERED PTFE STENTS (Viatorr) for TIPS — 80% 2-year patency vs 40% for bare stents; reduced shunt dysfunction and encephalopathy rates. Yamada\'s Gastroenterology 7th Ed., p. 2859.',
    'CARVEDILOL — third-generation NSBB with additional anti-α1 effect → also reduces hepatic vascular resistance (HSR); superior to propranolol/nadolol in some studies for CSPH; now recommended by BAVENO VII guidelines.',
    'NON-INVASIVE PORTAL PRESSURE ASSESSMENT: Liver stiffness + spleen stiffness (FibroScan + spleen stiffness model) can predict HVPG ≥10 mmHg (CSPH) and varices — reduces need for endoscopy screening in low-risk patients (BAVENO VI/VII criteria).',
    'BAVENO VI/VII CRITERIA: Spleen diameter <150 mm + FibroScan <20 kPa → low risk of varices → can avoid screening endoscopy. Saves ~50% of endoscopies.',
    'RIFAXIMIN (550 mg BD) + LACTULOSE — gold standard for secondary HE prophylaxis; reduces hospitalisation by 50% (TARGET trial).',
    'TERLIPRESSIN — Level 1A evidence for reducing mortality in acute variceal haemorrhage; approved in USA (2022, FDA) for HRS-AKI.',
    'SIMULTANEOUS LIVER-KIDNEY TRANSPLANTATION (SLK) — for concurrent HRS + AKI/CKD.',
    'BAVENO VII CONSENSUS (2022) — updated guidelines on portal hypertension management including NSBB withdrawal criteria and TIPS indication thresholds.',
    'ENDOSCOPIC ULTRASOUND-GUIDED COIL EMBOLISATION + CYANOACRYLATE INJECTION for gastric varices — emerging technique; avoids need for TIPS in isolated gastric varices.',
]
for a in advances: ab(a)
doc.add_paragraph()

# ─────────────────── SECTION 10: SCORING GUIDE ───────────────────
ah("10. EXAMINER'S SCORING GUIDE — 30 Marks", level=1)
at(['Section','Expected Marks'],
[
    ['Portal venous anatomy (formation + tributaries + portosystemic anastomoses — 5 sites — draw diagram)','5'],
    ['Definition + HVPG values + Classification of causes (pre/intra/post-hepatic — full table)','3'],
    ['Pathophysiology (resistance + flow; mechanisms of each complication)','3'],
    ['Clinical features (ALL signs — caput medusae, spider naevi, asterixis, splenomegaly, ascites etc.)','3'],
    ['Investigations (blood tests + SAAG + endoscopy + imaging + Child-Pugh / MELD)','3'],
    ['Management of acute variceal haemorrhage (terlipressin + antibiotics + EVL + SBT + TIPS)','5'],
    ['Secondary prophylaxis + Primary prophylaxis (NSBB + EVL + TIPS)','2'],
    ['Ascites management (diuretics + LVP + albumin + TIPS + SBP treatment)','2'],
    ['Surgical shunts (Warren splenorenal + portocaval + Sugiura) + Liver transplantation','3'],
    ['Recent advances (early TIPS, carvedilol, BAVENO VII, rifaximin, covered stents)','1'],
    ['TOTAL','30'],
])
doc.add_paragraph()

ah('Sharp-Edge Discriminators — Mark-Winners', level=2, color=(0x2E,0x75,0xB6))
tips=[
    'Portal vein = SMV + Splenic vein behind neck of pancreas at level L1/L2',
    'Normal HVPG = 3-5 mmHg; CSPH = ≥10 mmHg; variceal bleed threshold = >12 mmHg (Yamada\'s p. 2858)',
    '5 portosystemic anastomoses: lower oesophagus / anorectal junction / umbilicus / retroperitoneum (Retzius) / bare area of liver',
    'Flow in caput medusae = AWAY from umbilicus (unlike IVC obstruction where epigastric flow is upward)',
    'SAAG ≥1.1 g/dL = portal HTN ascites; <1.1 = non-portal HTN ascites (TB, malignancy, nephrotic)',
    'Terlipressin = Level 1A evidence; reduces portal pressure + 5-day mortality; start BEFORE endoscopy',
    'Antibiotics (ceftriaxone) are MANDATORY in acute variceal bleed — reduce early rebleeding and mortality',
    'Blood transfusion target Hb 70-80 g/L ONLY (restrictive) — over-transfusion INCREASES portal pressure and rebleed risk',
    'Sengstaken-Blakemore tube = TEMPORARY BRIDGE only (max 24 hours); always intubate first; replace with TIPS',
    'TIPS target HVPG <12 mmHg (varices) or <10 mmHg (ascites); covered PTFE stent (Viatorr) = 80% 2yr patency',
    'Warren shunt (DSRS) = SELECTIVE decompression — preserves portal hepatopetal flow — lower HE rate than total portocaval shunt',
    'Sugiura procedure = devascularisation without shunt — used in EHPVO (India/Asia) and CTP-C where portal vein unsuitable',
    'CTP-A = 10% operative mortality; CTP-B = 30%; CTP-C = 75-80% (Bailey & Love p. 1217)',
    'MELD >15 → liver transplant listing; each MELD point >20 = +2% operative mortality',
    'SBP diagnosis = PMN >250/mm³ in ascitic fluid; treat with ceftriaxone + IV albumin (1.5 g/kg Day 1 + 1 g/kg Day 3)',
    'Hepatic encephalopathy: Rifaximin 550 mg BD + Lactulose (secondary prophylaxis); Rifaximin avoids neomycin toxicity',
    'Schistosomiasis = most common cause of PRESINUSOIDAL intrahepatic portal HTN worldwide; EHPVO most common prehepatic cause in India',
    'Early TIPS (Garcia-Pagan trial, 2010): within 72h in high-risk CTP-B/C; reduced failure 50%→3%; improved 1yr survival',
]
for t in tips: ab(t)
doc.add_paragraph()
ps=doc.add_paragraph()
rs=ps.add_run("Sources: Bailey & Love's Short Practice of Surgery 28th Ed. (Ch. 69, p. 1217) | Yamada's Textbook of Gastroenterology 7th Ed. (p. 2857-2861) | Schwartz's Principles of Surgery 11th Ed. | Sabiston Textbook of Surgery 21st Ed. | Fischer's Mastery of Surgery 8th Ed.")
rs.italic=True; rs.font.size=Pt(9); rs.font.color.rgb=RGBColor(0x70,0x70,0x70)

out='/tmp/workspace/ms-surgery-notes/Portal_Hypertension_30marks.docx'
doc.save(out)
print(f'Saved: {out}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()
sec = doc.sections[0]
sec.top_margin = Cm(2); sec.bottom_margin = Cm(2)
sec.left_margin = Cm(2.5); sec.right_margin = Cm(2.5)
doc.styles['Normal'].font.name = 'Arial'
doc.styles['Normal'].font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def ah(text, level=1, color=(0x1F,0x4E,0x79)):
    p = doc.add_heading(text, level=level)
    for r in p.runs: r.font.color.rgb = RGBColor(*color)
    return p

def ap(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    r = p.add_run(text); r.bold=bold; r.italic=italic; r.font.size=Pt(size)
    if color: r.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def ab(text, bold=False):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    r = p.add_run(text); r.font.size=Pt(11); r.bold=bold
    return p

def scbg(cell, hx):
    tc=cell._tc; tcPr=tc.get_or_add_tcPr()
    shd=OxmlElement('w:shd')
    shd.set(qn('w:val'),'clear'); shd.set(qn('w:color'),'auto')
    shd.set(qn('w:fill'),hx); tcPr.append(shd)

def at(headers, rows, hc='1F4E79', arc='D6E4F0'):
    tbl=doc.add_table(rows=1+len(rows), cols=len(headers))
    tbl.style='Table Grid'
    hr=tbl.rows[0].cells
    for i,h in enumerate(headers):
        hr[i].text=h; scbg(hr[i],hc)
        for p in hr[i].paragraphs:
            for r in p.runs:
                r.bold=True; r.font.size=Pt(10); r.font.color.rgb=RGBColor(0xFF,0xFF,0xFF)
    for ri,rd in enumerate(rows):
        cs=tbl.rows[ri+1].cells
        for ci,txt in enumerate(rd):
            cs[ci].text=txt
            for p in cs[ci].paragraphs:
                for r in p.runs: r.font.size=Pt(10)
        if ri%2==0:
            for c in cs: scbg(c,arc)
    return tbl

def embed_img(url, path, w=Inches(5.5), cap=None):
    try:
        r=requests.get(url,timeout=15)
        if r.status_code==200:
            with open(path,'wb') as f: f.write(r.content)
            doc.add_picture(path,width=w)
            doc.paragraphs[-1].alignment=WD_ALIGN_PARAGRAPH.CENTER
            if cap:
                c=doc.add_paragraph(cap); c.alignment=WD_ALIGN_PARAGRAPH.CENTER
                c.runs[0].italic=True; c.runs[0].font.size=Pt(9)
    except:
        ap(f'[Image: {cap}]',italic=True,color=(0x70,0x70,0x70))

# ─── COVER ───
p=doc.add_paragraph(); p.alignment=WD_ALIGN_PARAGRAPH.CENTER
r=p.add_run('MS GENERAL SURGERY — EXAM NOTES')
r.bold=True; r.font.size=Pt(18); r.font.color.rgb=RGBColor(0x1F,0x4E,0x79)
p2=doc.add_paragraph(); p2.alignment=WD_ALIGN_PARAGRAPH.CENTER
r2=p2.add_run('Carcinoma of Colon and Rectum — 30-Mark Question')
r2.bold=True; r2.font.size=Pt(14); r2.font.color.rgb=RGBColor(0x2E,0x75,0xB6)
p3=doc.add_paragraph(); p3.alignment=WD_ALIGN_PARAGRAPH.CENTER
r3=p3.add_run("Sources: Bailey & Love 28th Ed. | Current Surgical Therapy 14e | Yamada's Gastroenterology 7th Ed. | Fischer's Mastery 8th Ed. | Sabiston 21st Ed.")
r3.italic=True; r3.font.size=Pt(10); r3.font.color.rgb=RGBColor(0x70,0x70,0x70)
doc.add_paragraph()
pq=doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Classify carcinoma of the colon and rectum. Describe its aetiology, pathology, staging, clinical features, investigations and management."   [30 Marks]').bold=True
pq.runs[0].font.size=Pt(11); pq.runs[0].font.color.rgb=RGBColor(0x7B,0x22,0x00)
doc.add_paragraph()

embed_img(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_bf293dee96e84a41e0ac959e9d0e3008575aacec78ae122af7b701556e424fb6.jpg',
    '/tmp/workspace/ms-surgery-notes/tme_surgery.jpg', w=Inches(5.5),
    cap='Figure 1: Laparoscopic Total Mesorectal Excision (TME) for rectal cancer. (a) IMA skeletonisation and ureter identification; (b) anterior rectal space dissection with seminal vesicles; (c-d) bilateral "holy plane" dissection preserving neurovascular bundles; (e) intact mesorectal specimen — complete TME; (f) opened specimen after neoadjuvant CRT with 1.5 cm residual tumour. (PMC / Current Surgical Therapy 14e)'
)
doc.add_paragraph()

# ─── SECTION 1: ANATOMY ───
ah('1. SURGICAL ANATOMY OF THE COLON AND RECTUM', level=1)
ap('EXAM TIP: Draw the colon with blood supply labelled — scores 3-4 marks.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Parts of the Colon and Rectum', level=2, color=(0x2E,0x75,0xB6))
at(['Part','Length','Relations / Features'],
[
    ['CAECUM','6 cm wide; in right iliac fossa','Appendix arises from posteromedial wall; ileocaecal valve; entirely intraperitoneal'],
    ['ASCENDING COLON','15 cm','Right flank; retroperitoneal; relations: right kidney, duodenum, liver (hepatic flexure)'],
    ['HEPATIC (RIGHT) FLEXURE','—','Right hypochondrium; below liver; attached to duodenum by hepatocolic ligament'],
    ['TRANSVERSE COLON','50 cm','Intraperitoneal; transverse mesocolon; hangs between hepatic + splenic flexures; stomach above, small bowel below'],
    ['SPLENIC (LEFT) FLEXURE','—','Higher and more acute than hepatic flexure; attached to diaphragm (phrenocolic ligament) — splenic ligament; near spleen + left kidney'],
    ['DESCENDING COLON','25 cm','Retroperitoneal; left flank'],
    ['SIGMOID COLON','25-40 cm','Intraperitoneal on sigmoid mesocolon; variable length; in pelvis; joins rectum at rectosigmoid junction (S3)'],
    ['RECTUM','12-15 cm','No taeniae coli; no appendices epiploicae; 3 lateral bends (valves of Houston); PERITONEAL COVERAGE: upper 1/3 anterior + both sides; middle 1/3 anterior only; lower 1/3 EXTRAPERITONEAL'],
    ['ANAL CANAL','3-4 cm','From anorectal junction to anal verge; divided by dentate/pectinate line (1.5 cm from verge); ABOVE dentate = columnar epithelium (visceral innervation); BELOW = squamous (somatic — painful)'],
])
doc.add_paragraph()

ah('Blood Supply', level=2, color=(0x2E,0x75,0xB6))
at(['Region','Artery','Origin','Vein → Portal Drainage'],
[
    ['Caecum, ascending colon, hepatic flexure, proximal transverse','ILEOCOLIC + RIGHT COLIC + MIDDLE COLIC (right branch)','Superior Mesenteric Artery (SMA)','Superior mesenteric vein → portal vein'],
    ['Distal transverse, splenic flexure (watershed)','MIDDLE COLIC (left branch)','SMA / SMA-IMA overlap zone','SMV → portal vein'],
    ['Descending colon, sigmoid colon','LEFT COLIC + SIGMOIDAL ARTERIES','Inferior Mesenteric Artery (IMA)','Inferior mesenteric vein → splenic vein → portal vein'],
    ['Upper rectum','SUPERIOR RECTAL ARTERY (continuation of IMA)','IMA','Superior rectal vein → IMV → portal vein'],
    ['Mid rectum','MIDDLE RECTAL ARTERIES','Internal iliac arteries','Middle rectal veins → internal iliac veins → systemic'],
    ['Lower rectum + anal canal','INFERIOR RECTAL ARTERIES','Internal pudendal arteries (from internal iliac)','Inferior rectal veins → pudendal veins → systemic'],
])
ap('WATERSHED ZONE: Splenic flexure + sigmoid/upper rectum (Sudeck\'s point) = areas most vulnerable to ischaemia during colonic surgery. Source: Current Surgical Therapy 14e (Colon Resection chapter).', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Lymphatic Drainage', level=2, color=(0x2E,0x75,0xB6))
at(['Region','Lymph Node Groups'],
[
    ['Colon (general)','Epicolic nodes (on bowel wall) → Paracolic nodes (along marginal artery) → Intermediate nodes (along named arteries) → Principal nodes (at SMA/IMA origin)'],
    ['Rectum (upper 2/3)','Upward along superior rectal + IMA nodes → para-aortic nodes'],
    ['Rectum (lower 1/3)','Lateral to internal iliac nodes; Downward via inferior rectal to inguinal nodes'],
    ['Below dentate line','INGUINAL lymph nodes (important: anal canal cancer below dentate line → inguinal nodal spread)'],
])
ap('Minimum 12 lymph nodes must be sampled in any colonic resection specimen to accurately stage the cancer. Source: Yamada\'s 7th Ed., p. — ; Current Surgical Therapy 14e, p. 295.', italic=True, color=(0x70,0x70,0x70), size=9)
doc.add_paragraph()

ah('Nerve Supply + Important Autonomic Nerves (Rectal Surgery)', level=2, color=(0x2E,0x75,0xB6))
at(['Nerve','Origin','Function','Risk in Rectal Surgery'],
[
    ['Hypogastric nerves (sympathetic)','Superior hypogastric plexus (pre-aortic) → divide at sacral promontory into right + left hypogastric nerves','Ejaculation + bladder neck closure','Injury at sacral promontory during dissection → retrograde ejaculation'],
    ['Pelvic splanchnic nerves (S2-S4; parasympathetic, nervi erigentes)','Sacral foramina S2-S4','Erection (males) + bladder detrusor function','Injury during lateral rectal dissection → impotence + urinary retention/incontinence'],
    ['Inferior hypogastric plexus (pelvic plexus)','Union of hypogastric nerves + pelvic splanchnic nerves','Combined sympathetic + parasympathetic; controls ALL pelvic organs','Injury at lateral stalks → combined sexual + bladder dysfunction'],
    ['Neurovascular bundles (Walsh bundles)','From inferior hypogastric plexus; travel along posterolateral rectum','Erection','Preserved in "holy plane" dissection during TME'],
])
doc.add_paragraph()

# ─── SECTION 2: EPIDEMIOLOGY ───
ah('2. EPIDEMIOLOGY AND RISK FACTORS', level=1)
ab('WORLDWIDE: 3rd most common cancer (colon #3; rectal #4); 2nd most common cause of cancer death in Western countries')
ab('INCIDENCE: ~100,000 new colon cancers + ~45,000 rectal cancers per year in USA (Current Surgical Therapy 14e)')
ab('MALE:FEMALE: Approximately equal; slight male predominance for rectal cancer')
ab('AGE: Peak incidence 60-80 years; <10% under 50 years (rising incidence in young adults — "early-onset CRC")')
ab('INDIA: Incidence rising; rectal cancer more prevalent than in West; presentation often late-stage')
doc.add_paragraph()
ah('Risk Factors', level=2, color=(0x2E,0x75,0xB6))
at(['Category','Risk Factor','Relative Risk'],
[
    ['DIETARY / LIFESTYLE','High red/processed meat; low fibre; high animal fat; obesity; physical inactivity; alcohol; smoking','↑ 1.5-2×'],
    ['INFLAMMATORY BOWEL DISEASE','ULCERATIVE COLITIS (extent + duration): pancolitis >8-10 years → 20-30× risk; Crohn\'s colitis','↑ 5-25×'],
    ['HEREDITARY SYNDROMES','FAMILIAL ADENOMATOUS POLYPOSIS (FAP): APC gene; 100% lifetime CRC risk if untreated','100% (FAP)'],
    ['','HEREDITARY NON-POLYPOSIS CRC (HNPCC / Lynch syndrome): MLH1/MSH2/MSH6/PMS2 genes; 70-80% lifetime risk','↑ 10-20×'],
    ['','MUTYH-associated polyposis; Peutz-Jeghers (STK11); Serrated polyposis','↑ variable'],
    ['POLYP HISTORY','Adenomatous polyp history (tubular, tubulovillous, villous adenoma — villous highest risk)','↑ 3-5×'],
    ['FAMILY HISTORY','First-degree relative with CRC: relative risk 2-3×','↑ 2-3×'],
    ['PREVIOUS CRC','3% risk of metachronous CRC','↑ 3×'],
    ['PROTECTIVE FACTORS','High-fibre diet; aspirin/NSAIDs (reduces adenoma recurrence); physical activity; statins','↓ risk'],
])
doc.add_paragraph()

# ─── SECTION 3: MOLECULAR / AETIOLOGY ───
ah('3. MOLECULAR PATHOGENESIS — ADENOMA-CARCINOMA SEQUENCE', level=1)
ap('The Vogelstein Model (1990): Step-wise accumulation of mutations in colon epithelium → adenoma → carcinoma. KEY HIGH-YIELD CONCEPT.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()
at(['Step','Gene','Chromosome','Effect'],
[
    ['1. Normal epithelium → Early adenoma','APC (tumour suppressor)','Chr 5q','Loss of APC → failure of beta-catenin degradation → uncontrolled Wnt signalling → cell proliferation. MUTATION IN >85% CRC. Also mutated in FAP.'],
    ['2. Early → Intermediate adenoma','KRAS (proto-oncogene)','Chr 12p','Activating point mutation → constitutive RAS-MAPK signalling → continuous cell division. Present in ~40% CRC. IMPORTANT: anti-EGFR therapy (cetuximab, panitumumab) ONLY works if KRAS is wild-type (not mutated).'],
    ['3. Intermediate → Late adenoma','SMAD2/SMAD4 (DCC — deleted in colon cancer)','Chr 18q','Loss of TGF-beta signalling → failure of growth inhibition'],
    ['4. Late adenoma → Carcinoma','TP53 (tumour suppressor)','Chr 17p','Loss of p53 → failure of apoptosis + DNA repair checkpoint → invasive carcinoma'],
    ['ALTERNATIVE PATHWAY: Serrated/MSI pathway','MLH1, MSH2, MSH6, PMS2 (mismatch repair genes)','Chr 3p (MLH1), 2p (MSH2)','Microsatellite instability (MSI-H / dMMR) → Lynch syndrome OR sporadic hypermethylation of MLH1 promoter. MSI-H tumours = better prognosis + respond to immunotherapy (pembrolizumab).'],
])
doc.add_paragraph()
ap('MSI-H (Microsatellite Instability-High) = dMMR (deficient mismatch repair): better prognosis; do NOT benefit from 5-FU alone; benefit from pembrolizumab (checkpoint inhibitor). Test ALL CRC for MMR/MSI status.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

# ─── SECTION 4: PATHOLOGY ───
ah('4. PATHOLOGY', level=1)
ah('Macroscopic Types', level=2, color=(0x2E,0x75,0xB6))
at(['Type','Appearance','Common Site','Features'],
[
    ['ANNULAR / STENOSING (most common in left colon)','Circumferential "napkin ring" / "apple-core" constriction on barium enema','Left colon, sigmoid, rectosigmoid','Causes obstructive symptoms + LBO; characteristic barium enema appearance'],
    ['POLYPOID / EXOPHYTIC (most common in right colon)','Fungating, cauliflower-like mass projecting into lumen','Caecum, ascending colon, right colon','Causes occult bleeding → anaemia; rarely obstructs (wide lumen)'],
    ['ULCERATIVE','Irregular, indurated ulcer with raised, rolled or everted edges','Rectum (most common macroscopic type in rectum)','Bleeding per rectum; mucus; tenesmus'],
    ['DIFFUSE / LINITIS PLASTICA','Diffuse thickening of wall','Rare in colon; seen in signet ring variant','Resembles gastric linitis plastica; aggressive'],
])
doc.add_paragraph()
ah('Microscopic (Histological) Types', level=2, color=(0x2E,0x75,0xB6))
at(['Type','Frequency','Notes'],
[
    ['ADENOCARCINOMA (well/moderately/poorly differentiated)','~85%','Glandular; most common; graded by gland formation: well (>95% glands) → moderate (50-95%) → poor (<50%)'],
    ['MUCINOUS (colloid) adenocarcinoma','10-15%','>50% mucin content; worse prognosis; more common in MSI-H/Lynch syndrome'],
    ['SIGNET RING CELL carcinoma','<1%','Intracellular mucin displaces nucleus; WORST prognosis; diffuse infiltration; young patients'],
    ['Squamous cell carcinoma','Rare','Anal canal below dentate line; also in UC squamous metaplasia'],
    ['Small cell carcinoma (NEC)','Very rare','High grade; rapid progression; treat like lung SCLC'],
    ['Carcinoid tumour (NET)','Rare','Rectum most common site; low malignant potential if <2 cm'],
])
doc.add_paragraph()
ah('Spread', level=2, color=(0x2E,0x75,0xB6))
at(['Route','Detail'],
[
    ['LOCAL (direct)','Circumferential: grows around bowel wall → obstruction. Longitudinal: slow (3 cm/year). Depth: mucosa → submucosa → muscularis propria → serosa/perirectal fat → adjacent organs (bladder, uterus, small bowel)'],
    ['LYMPHATIC (most important for staging)','Upward along lymphatic channels to epicolic → paracolic → intermediate → principal lymph nodes. Minimum 12 LN must be assessed for accurate staging. (Current Surgical Therapy 14e, p. 295)'],
    ['HAEMATOGENOUS','Via portal venous drainage → LIVER (most common metastatic site — 50%); Lungs (via systemic veins for rectal cancer — 15%); Bone, brain, adrenal (rare)'],
    ['PERITONEAL / TRANSCOELOMIC','Free perforation or surgical spillage → peritoneal deposits → carcinomatosis'],
    ['IMPLANTATION','Shed cells implant at anastomosis / surgical wounds / stoma sites'],
])
doc.add_paragraph()

# ─── SECTION 5: STAGING ───
ah('5. STAGING', level=1)
ap('KNOW BOTH DUKES AND TNM STAGING — examiner expects both. Draw or tabulate them.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()
ah("Dukes' Classification (1932) — Modified by Astler-Coller", level=2, color=(0x2E,0x75,0xB6))
at(["Dukes' Stage",'Astler-Coller','Pathology Description','5-Year Survival'],
[
    ['A','A','Tumour confined to MUCOSA + SUBMUCOSA (not through muscularis propria); No LN involvement','~95%'],
    ['B','B1','Tumour into but NOT through MUSCULARIS PROPRIA; No LN involvement','~85%'],
    ['B','B2','Tumour THROUGH muscularis propria (into perirectal fat/serosa/adjacent organs); No LN involvement','~65-75%'],
    ['C','C1','As B1 but WITH REGIONAL LYMPH NODE INVOLVEMENT','~35-45%'],
    ['C','C2','As B2 but WITH REGIONAL LYMPH NODE INVOLVEMENT','~25-30%'],
    ['D (Turnbull addition)','—','DISTANT METASTASES (liver, lung, peritoneum)','<5%'],
])
doc.add_paragraph()
ah('TNM Staging (AJCC 8th Edition) — Current Standard', level=2, color=(0x2E,0x75,0xB6))
at(['T / N / M','Definition'],
[
    ['T1','Invades submucosa'],
    ['T2','Invades muscularis propria'],
    ['T3','Through muscularis propria into pericolorectal tissues / subserosa'],
    ['T4a','Penetrates visceral peritoneum (serosa)'],
    ['T4b','Invades or adheres to adjacent organ/structure'],
    ['N0','No regional LN metastasis'],
    ['N1a','Metastasis in 1 regional LN'],
    ['N1b','Metastasis in 2-3 regional LNs'],
    ['N1c','Tumour deposit(s) without regional LN mets'],
    ['N2a','Metastasis in 4-6 regional LNs'],
    ['N2b','Metastasis in ≥7 regional LNs'],
    ['M0','No distant metastasis'],
    ['M1a','Metastasis to 1 organ (liver, lung, ovary, node beyond regional)'],
    ['M1b','Metastasis to 2+ sites/organs'],
    ['M1c','Peritoneal metastasis ± other organ involvement'],
])
doc.add_paragraph()
at(['Stage','TNM','Dukes Equivalent','5-Year Survival'],
[
    ['Stage I','T1-2, N0, M0','A','90-95%'],
    ['Stage IIA','T3, N0, M0','B2','75-80%'],
    ['Stage IIB','T4a, N0, M0','B2','65-70%'],
    ['Stage IIC','T4b, N0, M0','B3','55-60%'],
    ['Stage IIIA','T1-2, N1/N1c, M0','C1','70-80%'],
    ['Stage IIIB','T3-4a, N1; T2-3, N2a, M0','C1-C2','45-70%'],
    ['Stage IIIC','T4a-4b, N2; any T, N2b, M0','C2','30-50%'],
    ['Stage IVA','Any T, Any N, M1a','D','20-30% (resectable mets)'],
    ['Stage IVB','Any T, Any N, M1b','D','10-15%'],
    ['Stage IVC','Any T, Any N, M1c','D','<5%'],
])
doc.add_paragraph()
ap('CRM (Circumferential Resection Margin) — CRITICAL for rectal cancer: CRM ≤1 mm = positive margin → high local recurrence risk. MRI staging of rectal cancer specifically assesses CRM involvement.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

# ─── SECTION 6: CLINICAL FEATURES ───
ah('6. CLINICAL FEATURES', level=1)
ap('Classic teaching: LEFT vs RIGHT colon present differently due to luminal diameter, stool consistency, and tumour type.', bold=True, color=(0x1F,0x4E,0x79))
at(['Feature','RIGHT COLON (caecum, ascending, hepatic flexure)','LEFT COLON (descending, sigmoid)','RECTUM'],
[
    ['Lumen','WIDE (6 cm); liquid stool','NARROW (2-3 cm); formed stool','Variable; fixed by pelvis'],
    ['BLEEDING','Occult blood loss → IRON DEFICIENCY ANAEMIA (insidious; presents with fatigue, dyspnoea, CCF in elderly)','FRESH BLOOD mixed with stool (visible PR bleeding; haematochezia)','FRESH RED BLOOD per rectum on or with stool; mucus discharge'],
    ['PAIN','Right iliac fossa pain (vague, dull, persistent); intermittent colicky pain','LEFT-sided colicky abdominal pain; change in bowel habit','Rectal pain, tenesmus (sensation of incomplete evacuation after defaecation)'],
    ['OBSTRUCTION','RARE (wide lumen)','COMMON — change in bowel habit; constipation alternating with diarrhoea; LARGE BOWEL OBSTRUCTION (if advanced)','Incomplete evacuation; narrow stool calibre; increasing constipation; rarely acute obstruction'],
    ['MASS','Palpable right iliac fossa mass (Caecal carcinoma most likely to be palpable)','May not be palpable unless very large','Palpable on DIGITAL RECTAL EXAMINATION (DRE) — up to 70% of rectal cancers are palpable on DRE'],
    ['WEIGHT LOSS / ANOREXIA','Often present at diagnosis','Variable','Variable'],
    ['CONSTITUTIONAL SYMPTOMS','Fever (from tumour necrosis); sweating; weight loss','Bowel habit change dominates','Mucus per rectum; urgency; frequency'],
])
doc.add_paragraph()
ah('Symptoms by Site Mnemonic: "Right Side — A Cause for Dullness" (Anaemia, Cramps, Fluid in Peritoneum, Dull mass, Dull pain, no obstruction)', italic=True, color=(0x1F,0x4E,0x79))
doc.add_paragraph()
ah('Physical Examination Findings', level=2, color=(0x2E,0x75,0xB6))
ab('Digital Rectal Examination (DRE) — MANDATORY: palpates tumours in lower rectum (up to 8 cm); assesses distance from anal verge; sphincter tone; fixity; lymph nodes in pararectal space')
ab('Palpable abdominal mass (right colon > left colon)')
ab('Hepatomegaly (liver metastases)')
ab('Ascites (peritoneal metastases)')
ab('Left supraclavicular lymphadenopathy (Virchow\'s node / Troisier\'s sign) — late')
ab('Jaundice (liver metastases or biliary compression)')
ab('Anorectal varices (differentiate from haemorrhoids in portal hypertension)')
doc.add_paragraph()

# ─── SECTION 7: INVESTIGATIONS ───
ah('7. INVESTIGATIONS', level=1)
ah('Blood Tests', level=2, color=(0x2E,0x75,0xB6))
at(['Test','Finding / Significance'],
[
    ['FBC','Microcytic hypochromic IRON DEFICIENCY ANAEMIA (especially right colon)'],
    ['LFTs','Elevated ALP/bilirubin → liver metastases; hypoalbuminaemia → malnutrition'],
    ['Serum iron + TIBC + ferritin','Confirm iron deficiency anaemia; exclude other causes'],
    ['CEA (Carcinoembryonic Antigen)','NOT diagnostic; elevated in 60-80% CRC; used for POST-OPERATIVE SURVEILLANCE (rising CEA after curative resection = recurrence). Pre-op baseline essential.'],
    ['CA 19-9','Elevated in ~20% CRC; more useful in pancreatic cancer'],
    ['LDH','Elevated in widespread metastases'],
    ['Coagulation + renal function','Pre-operative assessment'],
    ['MMR/MSI testing (tissue biopsy)','ALL CRC must be tested for mismatch repair deficiency (dMMR/MSI-H) — guides adjuvant therapy + identifies Lynch syndrome'],
    ['KRAS, NRAS, BRAF mutation testing','Required for Stage IV disease before anti-EGFR therapy decision (cetuximab/panitumumab only effective if RAS wild-type)'],
])
doc.add_paragraph()
ah('Imaging', level=2, color=(0x2E,0x75,0xB6))
at(['Investigation','Findings / Role'],
[
    ['COLONOSCOPY (gold standard for diagnosis)','Visualise entire colon; biopsy; polypectomy; tattoo lesion for laparoscopic surgery; synchronous tumours/polyps (present in 3-5%)'],
    ['FLEXIBLE SIGMOIDOSCOPY','Limited to left colon + rectum; used when colonoscopy not possible; must be complemented by CT colonography for right colon'],
    ['CT COLONOGRAPHY (virtual colonoscopy)','Non-invasive; full colon assessment; staging simultaneously; alternative when colonoscopy incomplete; sensitivity 90-95% for polyps >10 mm'],
    ['BARIUM ENEMA','"Apple-core" / "napkin ring" appearance (annular carcinoma); now largely replaced by CT colonography; still used when other tests unavailable'],
    ['CT CHEST + ABDOMEN + PELVIS (contrast)\n— STAGING INVESTIGATION'],
    ['','Liver metastases (hypodense lesions on portal phase CT); pulmonary mets; peritoneal disease; lymphadenopathy; invasion of adjacent organs. Sensitivity 84%, Specificity 95% for hepatic mets (Current Surgical Therapy 14e, p. 299)'],
    ['MRI RECTUM — ESSENTIAL for rectal cancer staging','HIGH RESOLUTION MRI: T-stage; N-stage; CRM (circumferential resection margin); extramural vascular invasion (EMVI); mrTRG (tumour regression grade after neoadjuvant CRT); relationship to anal sphincters; guide surgical planning + neoadjuvant therapy decision'],
    ['Endorectal Ultrasound (ERUS / TRUS)','T-stage for early rectal cancer (T1-T2); better near-field resolution than MRI; guides local excision candidacy; less useful after neoadjuvant CRT'],
    ['FDG-PET/CT','Sensitivity 97%, Specificity 97% for hepatic mets (Current Surgical Therapy 14e, p. 299); used for: equivocal findings on CT/MRI; assessment before liver resection for metastases; restaging after neoadjuvant CRT; suspected recurrence'],
    ['Chest X-ray','Pulmonary metastases (cannonball); pleural effusion'],
])
doc.add_paragraph()

# ─── SECTION 8: MANAGEMENT ───
ah('8. MANAGEMENT', level=1)
ap('ALWAYS structure management as: (A) Pre-operative preparation, (B) Colon cancer surgery by segment, (C) Rectal cancer surgery (neoadjuvant + TME + types of operation), (D) Emergency surgery, (E) Adjuvant therapy, (F) Metastatic disease, (G) Surveillance.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('A. Pre-operative Preparation', level=2, color=(0x2E,0x75,0xB6))
ab('Full history, examination, fitness assessment (CPEX / cardiopulmonary exercise testing if high risk)')
ab('MDT (multidisciplinary team) discussion — surgeon, oncologist, radiologist, pathologist, CNS')
ab('Mechanical bowel preparation: NOW NOT ROUTINELY USED for colon surgery (no evidence benefit; increases electrolyte disturbance). Rectal surgery: selective bowel prep used.')
ab('Thromboprophylaxis: Low molecular weight heparin + TED stockings (high VTE risk in cancer surgery)')
ab('Antibiotics: Single-dose IV at induction (cefuroxime + metronidazole or co-amoxiclav)')
ab('Stoma marking: If colostomy or ileostomy anticipated — mark by stoma nurse (right/left iliac fossa)')
ab('Enhanced recovery after surgery (ERAS) protocol: Early mobilisation, oral feeding, minimise opioids, carbohydrate loading pre-op')
doc.add_paragraph()

ah('B. Surgical Management of COLON CANCER', level=2, color=(0x2E,0x75,0xB6))
ap('Principles: (1) High ligation of feeding vessel at origin; (2) En bloc resection of segment + mesentery; (3) 5-7 cm proximal + distal margins; (4) Minimum 12 lymph nodes; (5) Tension-free well-vascularised anastomosis. Source: Current Surgical Therapy 14e, p. 295.', bold=False, italic=True, color=(0x70,0x70,0x70), size=9)
at(['Location','Operation','Vessels Ligated','Anastomosis'],
[
    ['CAECUM / ASCENDING COLON / HEPATIC FLEXURE','RIGHT HEMICOLECTOMY','High ligation of ileocolic artery + right colic artery (at SMA origin); preserve middle colic','Ileotransverse anastomosis (side-to-side or end-to-side)'],
    ['TRANSVERSE COLON (mid/distal)','EXTENDED RIGHT HEMICOLECTOMY','Ileocolic + right colic + middle colic artery ligation (entire)','Ileodescending anastomosis'],
    ['SPLENIC FLEXURE / DESCENDING COLON','LEFT HEMICOLECTOMY or EXTENDED LEFT HEMICOLECTOMY','Left colic artery (+ left branch of middle colic) OR high IMA ligation','Transverse to sigmoid anastomosis; or descending to upper rectum'],
    ['SIGMOID COLON','ANTERIOR RESECTION (high) / SIGMOID COLECTOMY','High ligation of IMA at origin; sigmoid arteries','Descending colon to upper rectum (colorectal anastomosis)'],
    ['COMPLETE MESOCOLIC EXCISION (CME)','Oncologically superior equivalent of TME for colon — sharp dissection along embryological planes; high vascular tie at SMA origin; increased lymph node yield. Gaining adoption.','—','—'],
])
doc.add_paragraph()

ah('C. Surgical Management of RECTAL CANCER — TME and Types of Resection', level=2, color=(0x2E,0x75,0xB6))
ap('TOTAL MESORECTAL EXCISION (TME) = sharp dissection along the "holy plane" between the mesorectal fascia (visceral) and presacral fascia (parietal) — removes rectum + entire mesorectal package en bloc. Introduced by R.J. Heald (1982). Reduces local recurrence from 30-40% to <5-10%. Mandatory for all mid/low rectal cancers.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ap('TME Key Steps (laparoscopic or open):', bold=True, color=(0x1F,0x4E,0x79))
ab('1. IMA identified + ligated high (preserving superior hypogastric plexus at sacral promontory)')
ab('2. Medial-to-lateral dissection: ureter + gonadal vessels swept posteriorly')
ab('3. Posterior plane: "holy plane" entered behind mesorectal fascia; presacral space developed (avascular); autonomic nerve bundles identified and preserved')
ab('4. Anterior plane: Denonvilliers\' fascia dissected from seminal vesicles/prostate (males) or posterior vagina (females)')
ab('5. Lateral planes: Lateral ligaments divided; pelvic plexus neurovascular bundles (Walsh bundles) preserved bilaterally')
ab('6. Distal transection: 1-2 cm distal margin below tumour; stapled transection')
ab('7. Anastomosis: circular stapled colorectal / coloanal anastomosis ± defunctioning loop ileostomy')
doc.add_paragraph()

at(['Operation','Indication','Technique','Stoma'],
[
    ['HIGH ANTERIOR RESECTION (HAR)','Upper rectal cancer (>10 cm from anal verge) + sigmoid cancers','Partial TME + colorectal anastomosis; IMA ligated high; sigmoid + upper rectum removed','Usually none required; protective ileostomy if high anastomotic risk'],
    ['LOW ANTERIOR RESECTION (LAR)','Mid rectal cancer (5-10 cm from anal verge)','Complete TME; ultra-low stapled colorectal anastomosis','Defunctioning loop ileostomy (MANDATORY — reduces anastomotic leak consequences)'],
    ['COLOANAL ANASTOMOSIS (Parks\')','Very low rectal cancer (3-5 cm from anal verge); sphincters intact','Complete TME + transanal mucosectomy + hand-sewn coloanal anastomosis with J-pouch coloplasty','Defunctioning loop ileostomy'],
    ['ABDOMINOPERINEAL RESECTION (APR / Miles\' operation)','LOWEST rectal cancers (<3 cm from anal verge); sphincter involvement; poor sphincter function; unable to achieve 1 cm distal margin','Two surgical phases: (1) Abdominal — sigmoid colon, rectum + mesorectum mobilised; (2) Perineal — anal canal + sphincters excised. Permanent end colostomy.','PERMANENT END COLOSTOMY (sigmoid) in left iliac fossa — no rectum remains'],
    ['HARTMANN\'S OPERATION','Emergency or palliative; CTP-C + perforation; too unwell for anastomosis; obstructing rectal/sigmoid cancer; prior pelvic irradiation','Sigmoid/upper rectum resected; proximal end colostomy formed; rectal stump oversewn','End colostomy (may be reversed later — Hartmann\'s reversal, but 30-40% never reversed — Fischer\'s Mastery 14e)'],
    ['TRANSANAL ENDOSCOPIC MICROSURGERY (TEM / TAMIS)','Early T1-T2 rectal cancer ≤3 cm; well-differentiated; no LVI; no LN involvement on MRI; low rectal <8 cm from anal verge','Endoscopic full-thickness local excision through transanal platform; avoids major laparotomy','None — outpatient/day case procedure'],
])
doc.add_paragraph()

ap('Sphincter-sparing is possible in tumours ≥5 cm from the anal verge in most cases. Below this, APR is required unless sphincter function is adequate AND negative distal margin (≥1 cm) can be achieved. Source: Yamada\'s Gastroenterology 7th Ed., p. 2178-2180.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Mesorectal Specimen Quality (Nagtegaal Grading)', level=2, color=(0x2E,0x75,0xB6))
at(['Grade','Description','Outcome'],
[
    ['COMPLETE (Grade 1)','Intact, smooth mesorectal fascia; no defect deeper than 5 mm; smooth coning distally','Best; lowest local recurrence'],
    ['NEARLY COMPLETE (Grade 2)','Moderate bulk of mesorectum; irregular surface; no exposure of muscularis propria','Intermediate'],
    ['INCOMPLETE (Grade 3)','Little mesorectal tissue; muscularis propria visible; deep defects','Worst; high local recurrence risk'],
])
doc.add_paragraph()

ah('D. Emergency Surgery for Colorectal Cancer', level=2, color=(0x2E,0x75,0xB6))
ap('Indications: Large bowel obstruction (LBO), perforation, bleeding.', bold=False)
at(['Presentation','Management'],
[
    ['LARGE BOWEL OBSTRUCTION (LBO) from colon cancer','Right-sided: Right hemicolectomy + primary anastomosis (safe — small bowel to transverse); Left-sided: Hartmann\'s procedure (sigmoid resection + end colostomy; safest in unprepared bowel) OR on-table lavage + primary anastomosis in selected fit patients OR self-expanding metallic stent (SEMS) as bridge to elective surgery'],
    ['ACUTE PERFORATION with peritonitis','Emergency Hartmann\'s or right hemicolectomy; damage control; washout; no primary anastomosis in faecal peritonitis'],
    ['MASSIVE PR HAEMORRHAGE','CT angiography + selective embolisation; urgent colonoscopy; surgical resection if refractory'],
    ['SEMS (Self-expanding metallic colonic stent)','Used as BRIDGE TO SURGERY in left-sided malignant LBO: decompresses colon → bowel prep → elective laparoscopic surgery within 2-4 weeks → avoids emergency stoma; 85% technical success'],
])
doc.add_paragraph()

ah('E. Neoadjuvant + Adjuvant Therapy', level=2, color=(0x2E,0x75,0xB6))
ap('RECTAL CANCER — Neoadjuvant Therapy (BEFORE surgery) for Stage II-III (T3-T4 or N+):', bold=True, color=(0x1F,0x4E,0x79))
at(['Regimen','Protocol','Evidence'],
[
    ['STANDARD LONG-COURSE CHEMORADIOTHERAPY (LCRT)','Radiotherapy 50.4 Gy in 28 fractions (5.5 weeks) + concurrent Capecitabine or 5-FU; surgery 6-8 weeks after completion','Reduces local recurrence; tumour downstaging; pCR rate 12-16% (Polish II trial). Source: Current Surgical Therapy 14e, p. 304'],
    ['SHORT-COURSE RADIOTHERAPY (SCRT)','5 Gy × 5 fractions (25 Gy total); NO concurrent chemotherapy; 8-12 weeks before surgery (with or without additional FOLFOX cycles)','Polish II trial: Equivalent oncological outcomes to LCRT; lower acute toxicity Grade ≥3'],
    ['TOTAL NEOADJUVANT THERAPY (TNT)','All chemotherapy + radiotherapy given BEFORE surgery (e.g., SCRT followed by FOLFOX × 4-6 cycles → surgery)','RAPIDO, PRODIGE 23, CAO/ARO/AIO-12 trials: pCR rates 25-30%; reduces distant metastases; allows "watch and wait" strategy for clinical complete response'],
    ['TARGETED THERAPY (MSI-H tumours — NEOADJUVANT)','Pembrolizumab (anti-PD-1) for dMMR/MSI-H locally advanced rectal cancer; KEYNOTE-177 context','Small case series/trials: 100% pCR in some MSI-H rectal cancers → may avoid surgery entirely (NEJM 2022 Cercek)'],
])
doc.add_paragraph()
ap('COLON CANCER — Adjuvant Therapy (AFTER surgery):', bold=True, color=(0x1F,0x4E,0x79))
at(['Stage','Adjuvant Therapy','Regimen'],
[
    ['Stage I (T1-2, N0)','NO adjuvant chemotherapy','Surgery alone — excellent prognosis'],
    ['Stage II (T3-4, N0) LOW RISK (pMMR/MSS, no high-risk features)','Observation OR 5-FU/capecitabine monotherapy','High-risk features: T4, LVI, perineural invasion, poor differentiation, <12 LN, obstruction/perforation at presentation'],
    ['Stage II HIGH RISK (pMMR) OR Stage II dMMR/MSI-H','FOLFOX or CAPOX × 6 months (oxaliplatin + 5-FU/capecitabine) for high-risk pMMR. NOTE: dMMR Stage II does NOT benefit from 5-FU alone; may observe or use FOLFOX','Source: Current Surgical Therapy 14e adjuvant algorithm (p. 300-301)'],
    ['Stage III (any T, N1-2)','FOLFOX (5-FU + Leucovorin + Oxaliplatin) OR CAPOX (Capecitabine + Oxaliplatin) × 6 months','Standard of care — reduces recurrence by 20-25%; improves OS by 10-15%'],
    ['Stage IV (Metastatic) — FIRST LINE','FOLFOX + Bevacizumab (anti-VEGF) OR FOLFIRI + Bevacizumab; FOLFOXIRI + Bevacizumab for fit patients','Median OS ~30 months with modern regimens'],
    ['Stage IV + RAS wild-type + LEFT-sided primary','Add EGFR-targeted therapy: Cetuximab OR Panitumumab + FOLFOX/FOLFIRI','KRAS/NRAS must be WILD-TYPE; BRAF V600E mutation → poor response to anti-EGFR'],
    ['Stage IV + dMMR/MSI-H','PEMBROLIZUMAB (anti-PD-1) first-line — KEYNOTE-177: superior PFS vs chemotherapy','MSI-H = 5% of metastatic CRC; best response to immunotherapy'],
    ['Stage IV + HER2-amplified (3-5%)','Tucatinib + Trastuzumab (HER2CLIMB-04)','Emerging targeted therapy'],
])
doc.add_paragraph()

ah('F. Management of Liver Metastases', level=2, color=(0x2E,0x75,0xB6))
ab('50% of CRC patients develop liver metastases at some point')
ab('SURGICAL RESECTION of liver metastases: POTENTIALLY CURATIVE if resectable (20-25% of patients with liver mets are resectable); 5-year survival 40-50% after R0 liver resection')
ab('Criteria for resectability: adequate liver remnant (≥30% of normal liver volume, or ≥40% if post-chemotherapy); R0 resection achievable; controlled primary; no extrahepatic disease OR limited resectable extrahepatic disease')
ab('CONVERSION CHEMOTHERAPY: Downsize unresectable liver mets → resectable; FOLFOX/FOLFIRI ± bevacizumab/cetuximab (RAS wild-type)')
ab('Portal vein embolisation (PVE): Induces hypertrophy of future liver remnant before major hepatectomy')
ab('Ablative therapies: Radiofrequency ablation (RFA) / Microwave ablation (MWA) for small (≤3 cm) unresectable mets; thermal destruction; combined with resection')
ab('Stereotactic body radiation therapy (SBRT): Oligometastatic disease; non-surgical candidates')
ab('Hepatic arterial infusion (HAI) pump: Intra-arterial FUDR for liver-only mets refractory to systemic therapy')
ab('SIRT (Selective internal radiation therapy): Yttrium-90 microspheres for liver-only or liver-dominant disease')
doc.add_paragraph()

ah('G. Surveillance After Curative Resection', level=2, color=(0x2E,0x75,0xB6))
at(['Timeline','Investigation'],
[
    ['3-6 months post-op','History + examination + serum CEA (baseline established pre-op; rising CEA = recurrence until proven otherwise)'],
    ['Every 6 months for 3 years','CEA; clinical assessment'],
    ['CT chest/abdomen/pelvis','At 6-12 months; 3 years; 5 years (detects hepatic + pulmonary recurrence)'],
    ['COLONOSCOPY','At 1 year post-op (detect metachronous lesions); then every 3-5 years if clear'],
    ['MRI pelvis','Rectal cancer surveillance: every 6 months for 3 years (local recurrence)'],
])
doc.add_paragraph()

# ─── SECTION 9: COMPLICATIONS ───
ah('9. COMPLICATIONS OF COLORECTAL SURGERY', level=1)
at(['Complication','Timing','Notes'],
[
    ['ANASTOMOTIC LEAK','Day 4-7 (peak)','Most serious; fever + peritonism + elevated CRP day 3-5; CT-guided drain or re-operation; defunctioning loop ileostomy prophylaxis in low anterior resection'],
    ['WOUND INFECTION','Day 5-10','More common after emergency surgery + obese + diabetes'],
    ['PARALYTIC ILEUS','Day 1-3','Early feeding (ERAS protocol) reduces duration; exclude obstruction'],
    ['HAEMORRHAGE','Immediate or Day 5-7','Anastomotic suture line bleed → haematochezia; mesenteric vessel bleed'],
    ['URINARY RETENTION / INJURY','Post-op (rectal surgery)','Bladder injury (1%); ureter injury (0.5-1%); catheterisation 5-7 days post rectal surgery; pelvic autonomic nerve injury → bladder dysfunction'],
    ['SEXUAL DYSFUNCTION','Post rectal surgery','Impotence in 10-30% males; retrograde ejaculation in 5-10%; dyspareunia in females; nerve-sparing "holy plane" TME reduces this'],
    ['LOW ANTERIOR RESECTION SYNDROME (LARS)','Long-term','Urgency, frequency, clustering, soiling after anterior resection; higher with ultra-low anastomosis; LARS score used to grade severity'],
    ['STOMA COMPLICATIONS','Immediate + long-term','Skin excoriation; prolapse; retraction; parastomal hernia; ischaemia/necrosis (immediate); obstruction'],
    ['PHANTOM RECTUM','After APR','Sensation of phantom rectal fullness/urgency after APR; usually improves with time'],
    ['TUMOUR RECURRENCE','Months-years','Local (mesorectal, pelvic) or distant (liver, lung); CEA surveillance + CT; re-resection if feasible'],
])
doc.add_paragraph()

# ─── SECTION 10: HEREDITARY SYNDROMES SHORT NOTE ───
ah('10. HEREDITARY COLORECTAL CANCER SYNDROMES (SHORT NOTE)', level=1)
at(['Syndrome','Gene','Genetics','Features','Screening + Management'],
[
    ['FAMILIAL ADENOMATOUS POLYPOSIS (FAP)','APC (chr 5q)','Autosomal dominant; 100% penetrance','100s-1000s of colorectal polyps; onset puberty; 100% CRC risk if untreated by 40s; extra-colonic: duodenal/ampullary polyps, desmoid tumours, CHRPE, osteomas (Gardner\'s syndrome), medulloblastoma (Turcot\'s)','Screening colonoscopy from age 10-12; PROPHYLACTIC COLECTOMY at ~18-20 years (IPAA — ileal pouch-anal anastomosis preferred; proctocolectomy + end ileostomy if CA develops); Celecoxib reduces polyps (temporary)'],
    ['LYNCH SYNDROME (HNPCC)','MLH1, MSH2, MSH6, PMS2 (mismatch repair genes)','Autosomal dominant; 70-80% CRC lifetime risk','Right-sided CRC predominance; MSI-H; early onset (40-50s); Extra-colonic: endometrial (60%), ovarian (10%), gastric, urinary, small bowel cancer; Amsterdam II criteria + Bethesda guidelines for testing','Annual colonoscopy from age 20-25 (or 10 years before youngest affected relative); aspirin chemoprevention (CaPP3 trial); consider prophylactic hysterectomy + BSO (females) at completion of family; pembrolizumab for MSI-H CRC'],
    ['MUTYH-ASSOCIATED POLYPOSIS (MAP)','MUTYH (base excision repair)','Autosomal RECESSIVE (unlike FAP + Lynch which are dominant)','10-100 adenomatous polyps; clinically similar to attenuated FAP; CRC risk elevated','Colonoscopy every 1-2 years; colectomy if polyposis uncontrolled'],
    ['PEUTZ-JEGHERS SYNDROME (PJS)','STK11 (serine threonine kinase 11)','Autosomal dominant','HAMARTOMATOUS polyps (not adenomatous); oromucocutaneous MELANIN SPOTS (lips, buccal mucosa, digits); CRC risk elevated; other cancers: breast, ovarian, pancreatic, gastric','Biannual colonoscopy; upper GI endoscopy; capsule endoscopy for small bowel; manage polyps endoscopically; small bowel resection for obstruction'],
])
doc.add_paragraph()

# ─── SECTION 11: RECENT ADVANCES ───
ah('11. RECENT ADVANCES', level=1)
advances=[
    'LAPAROSCOPIC + ROBOTIC COLORECTAL SURGERY: Laparoscopic colectomy (COLOR, COST, CLASICC trials): equivalent oncological outcomes to open; shorter stay; faster recovery. Now standard for elective colon cancer. Robot-assisted TME: better visualisation in narrow pelvis; improved nerve preservation; equivalent oncological outcomes.',
    'TRANSANAL TME (TaTME): Transanal total mesorectal excision from below upward — better access to distal rectum in obese/narrow pelvis patients; avoids difficult pelvic dissection from above; emerging technique for low rectal cancer.',
    'TOTAL NEOADJUVANT THERAPY (TNT): All neoadjuvant treatment (SCRT + FOLFOX) given before surgery — RAPIDO trial: TNT superior to standard CRT; pCR ~28%; reduces distant metastases; watch-and-wait for clinical complete responders.',
    '"WATCH AND WAIT" (Organ Preservation) for rectal cancer: After TNT in patients with CLINICAL COMPLETE RESPONSE (cCR) — no surgery; intensive surveillance (MRI + endoscopy); ~25-30% of patients achieve cCR; 3-year distant metastasis-free survival comparable to TME in selected patients (Habr-Gama series; IWWD).',
    'PEMBROLIZUMAB for dMMR/MSI-H rectal cancer (Cercek, NEJM 2022): 100% pCR in 12/12 patients with MSI-H locally advanced rectal cancer — ALL avoided surgery. Practice-changing — the first disease-site-specific use of immunotherapy as primary treatment to avoid surgery.',
    'COMPLETE MESOCOLIC EXCISION (CME): Oncological equivalent of TME for colon cancer — sharp dissection in embryological planes; higher lymph node yield; lower locoregional recurrence. ESCP endorsed.',
    'LIQUID BIOPSY (ctDNA — circulating tumour DNA): Post-operative ctDNA positivity predicts recurrence with high accuracy; allows risk-stratified adjuvant therapy decisions; DYNAMIC trial: ctDNA-guided adjuvant therapy in Stage II CRC.',
    'SEMS (Self-expanding metallic stent) as bridge to elective surgery in malignant LBO — ESCO trial: avoids emergency stoma in 85%; allows minimally invasive elective surgery.',
    'FOLFOXIRI + BEVACIZUMAB (TRIBE trial): Superior OS/PFS vs FOLFIRI + Bevacizumab in metastatic CRC; option for fit patients with high disease burden.',
    'HER2-TARGETED THERAPY (Tucatinib + Trastuzumab; MOUNTAINEER trial; HER2CLIMB-04): For HER2-amplified RAS/BRAF wild-type metastatic CRC (~3-5%); ORR 38%; new FDA approval 2023.',
]
for a in advances: ab(a)
doc.add_paragraph()

# ─── SECTION 12: SCORING GUIDE ───
ah("12. EXAMINER'S SCORING GUIDE — 30 Marks", level=1)
at(['Section','Marks'],
[
    ['Surgical anatomy of colon + rectum (parts + blood supply + lymphatics + autonomic nerves in pelvis)','4'],
    ['Epidemiology + risk factors (FAP, Lynch, UC, diet)','2'],
    ['Molecular pathogenesis (adenoma-carcinoma sequence — APC → KRAS → p53)','2'],
    ['Pathology (macroscopic + histological types + spread)','3'],
    ['Staging (BOTH Dukes\' classification + TNM AJCC — full tables with survival)','4'],
    ['Clinical features (left vs right vs rectal — differential table; DRE)','3'],
    ['Investigations (CEA, colonoscopy, MRI rectum, CT staging, PET, MMR/MSI)','3'],
    ['Surgical management (colon: hemicolectomy by segment; rectal: TME + types of operations)','5'],
    ['Adjuvant + neoadjuvant therapy (FOLFOX, chemoRT, TNT, immunotherapy for MSI-H)','3'],
    ['Recent advances (laparoscopic/robotic, TaTME, watch-and-wait, pembrolizumab, ctDNA)','1'],
    ['TOTAL','30'],
])
doc.add_paragraph()

ah('Sharp-Edge Discriminators — Mark-Winners', level=2, color=(0x2E,0x75,0xB6))
tips=[
    'RIGHT colon cancer → iron deficiency anaemia + right iliac fossa mass; LEFT colon cancer → obstruction + PR bleeding + bowel habit change',
    'VILLOUS adenoma: highest risk of malignant transformation (40% when >2 cm); most mucus production; secretory diarrhoea',
    'Minimum 12 lymph nodes must be examined in any colon cancer specimen (ASCO/NCCN/ACS quality standard). Source: Current Surgical Therapy 14e p. 295.',
    'DUKES D = Turnbull\'s addition (not original Dukes); Dukes original had only A/B/C',
    'CRM ≤1 mm = involved margin → high local recurrence risk in rectal cancer; MRI must specifically report CRM',
    'TME introduced by R.J. Heald (1982) — reduced local recurrence from 30-40% to <5-10%',
    'APR (Miles\' operation): PERMANENT end colostomy; used when distal margin <1 cm OR sphincter involvement',
    'Hartmann\'s procedure: Resection + end colostomy WITHOUT anastomosis — for emergency; up to 1/3 never reversed',
    'Low anterior resection ALWAYS needs defunctioning loop ileostomy — reduces consequences of anastomotic leak',
    'FAP = APC gene (chr 5q); autosomal dominant; 100% CRC; IPAA (ileal pouch-anal anastomosis) is preferred operation',
    'Lynch syndrome = MLH1/MSH2/MSH6/PMS2; MSI-H; endometrial cancer 60% lifetime risk; Amsterdam II criteria',
    'KRAS mutation → anti-EGFR therapy (cetuximab/panitumumab) does NOT work — must test KRAS before prescribing',
    'MSI-H/dMMR → Pembrolizumab works (KEYNOTE-158/177); standard 5-FU alone does NOT benefit MSI-H Stage II CRC',
    '"Watch and wait" for rectal cancer after TNT with cCR: 100% pCR in MSI-H tumours with pembrolizumab (Cercek NEJM 2022)',
    'Splenic flexure = WATERSHED zone (SMA/IMA border) — ischaemia risk during both arterial occlusion and high ligation',
    'CEA NOT used for diagnosis — only for POST-OPERATIVE SURVEILLANCE (rising CEA = recurrence)',
    'Neoadjuvant long-course CRT for rectal cancer: 50.4 Gy + concurrent capecitabine → surgery after 6-8 weeks; pCR 12-16%',
    'Short-course RT (SCRT) 5×5 Gy = Polish II trial: equivalent to long-course CRT; lower toxicity; good for elderly/frail patients',
]
for t in tips: ab(t)
doc.add_paragraph()
ps=doc.add_paragraph()
rs=ps.add_run("Sources: Bailey & Love's Short Practice of Surgery 28th Ed. (Ch. 77) | Current Surgical Therapy 14e (p. 295-310) | Yamada's Textbook of Gastroenterology 7th Ed. (p. 2166-2185) | Fischer's Mastery of Surgery 8th Ed. (Ch. 141-142) | Sabiston Textbook of Surgery 21st Ed.")
rs.italic=True; rs.font.size=Pt(9); rs.font.color.rgb=RGBColor(0x70,0x70,0x70)

out='/tmp/workspace/ms-surgery-notes/CRC_30marks.docx'
doc.save(out)
print(f'Saved: {out}')

Successfully replaced 1 instance(s) of the string in '/tmp/workspace/ms-surgery-notes/create_crc_docx.py'

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()
sec = doc.sections[0]
sec.top_margin = Cm(2); sec.bottom_margin = Cm(2)
sec.left_margin = Cm(2.5); sec.right_margin = Cm(2.5)
doc.styles['Normal'].font.name = 'Arial'
doc.styles['Normal'].font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def ah(text, level=1, color=(0x1F,0x4E,0x79)):
    p = doc.add_heading(text, level=level)
    for r in p.runs: r.font.color.rgb = RGBColor(*color)
    return p

def ap(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    r = p.add_run(text); r.bold=bold; r.italic=italic; r.font.size=Pt(size)
    if color: r.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def ab(text, bold=False):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    r = p.add_run(text); r.font.size=Pt(11); r.bold=bold
    return p

def scbg(cell, hx):
    tc=cell._tc; tcPr=tc.get_or_add_tcPr()
    shd=OxmlElement('w:shd')
    shd.set(qn('w:val'),'clear'); shd.set(qn('w:color'),'auto')
    shd.set(qn('w:fill'),hx); tcPr.append(shd)

def at(headers, rows, hc='1F4E79', arc='D6E4F0'):
    tbl=doc.add_table(rows=1+len(rows), cols=len(headers))
    tbl.style='Table Grid'
    hr=tbl.rows[0].cells
    for i,h in enumerate(headers):
        hr[i].text=h; scbg(hr[i],hc)
        for p in hr[i].paragraphs:
            for r in p.runs:
                r.bold=True; r.font.size=Pt(10); r.font.color.rgb=RGBColor(0xFF,0xFF,0xFF)
    for ri,rd in enumerate(rows):
        cs=tbl.rows[ri+1].cells
        for ci,txt in enumerate(rd):
            cs[ci].text=txt
            for p in cs[ci].paragraphs:
                for r in p.runs: r.font.size=Pt(10)
        if ri%2==0:
            for c in cs: scbg(c,arc)
    return tbl

def embed_img(url, path, w=Inches(5.5), cap=None):
    try:
        r=requests.get(url,timeout=15)
        if r.status_code==200:
            with open(path,'wb') as f: f.write(r.content)
            doc.add_picture(path,width=w)
            doc.paragraphs[-1].alignment=WD_ALIGN_PARAGRAPH.CENTER
            if cap:
                c=doc.add_paragraph(cap); c.alignment=WD_ALIGN_PARAGRAPH.CENTER
                c.runs[0].italic=True; c.runs[0].font.size=Pt(9)
    except:
        ap(f'[Image: {cap}]',italic=True,color=(0x70,0x70,0x70))

# ─── COVER ───
p=doc.add_paragraph(); p.alignment=WD_ALIGN_PARAGRAPH.CENTER
r=p.add_run('MS GENERAL SURGERY — EXAM NOTES')
r.bold=True; r.font.size=Pt(18); r.font.color.rgb=RGBColor(0x1F,0x4E,0x79)
p2=doc.add_paragraph(); p2.alignment=WD_ALIGN_PARAGRAPH.CENTER
r2=p2.add_run('Acute Pancreatitis — 30-Mark Question')
r2.bold=True; r2.font.size=Pt(14); r2.font.color.rgb=RGBColor(0x2E,0x75,0xB6)
p3=doc.add_paragraph(); p3.alignment=WD_ALIGN_PARAGRAPH.CENTER
r3=p3.add_run("Sources: Sleisenger & Fordtran's GI Disease 11th Ed. | Bailey & Love 28th Ed. | Maingot's Abdominal Operations | Current Surgical Therapy 14e | Yamada's 7th Ed. | Schwartz's 11th Ed.")
r3.italic=True; r3.font.size=Pt(10); r3.font.color.rgb=RGBColor(0x70,0x70,0x70)
doc.add_paragraph()
pq=doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Define Acute Pancreatitis. Describe its aetiology, pathophysiology, clinical features, severity assessment, investigations and management including complications."   [30 Marks]').bold=True
pq.runs[0].font.size=Pt(11); pq.runs[0].font.color.rgb=RGBColor(0x7B,0x22,0x00)
doc.add_paragraph()

embed_img(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_139eb323dcf8d3eb395a77d114b5f391b83fa5e878e0c9d51d827c7f1d7db9c8.jpg',
    '/tmp/workspace/ms-surgery-notes/pancreatitis_ct.jpg', w=Inches(5.5),
    cap='Figure 1: CECT abdomen — Severe acute necrotizing pancreatitis. Green arrow: necrotic body/tail of pancreas (heterogeneous enhancement). White arrow: extensive peripancreatic fluid collection extending into pararenal space. (Sleisenger & Fordtran / PMC)'
)
embed_img(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_3cfbad4dd840c2ae0a77c368d1efb4040901184b5250b5d7a5da9be2b5ca8d88.jpg',
    '/tmp/workspace/ms-surgery-notes/infected_necrosis_ct.jpg', w=Inches(5.5),
    cap='Figure 2: CECT abdomen — Infected pancreatic necrosis. Bubbles of gas (air) within the peripancreatic collection are PATHOGNOMONIC of infected necrosis. Left: axial view; Right: coronal view. These are Acute Necrotic Collections (ANC) — no thick wall yet (< 4 weeks). Gas = infection until proven otherwise.'
)
doc.add_paragraph()

# ─── SECTION 1: ANATOMY ───
ah('1. SURGICAL ANATOMY OF THE PANCREAS', level=1)
ap('EXAM TIP: Draw the pancreas showing its parts, relations, ductal system and blood supply — scores 3-4 marks.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Parts, Position and Key Relations', level=2, color=(0x2E,0x75,0xB6))
at(['Part','Position','Key Relations / Applied Anatomy'],
[
    ['HEAD (including UNCINATE PROCESS)','Right of L1/L2; lies in C-loop of duodenum','Posterior: IVC, portal vein (confluence of SMV + splenic vein); CBD passes through head. Uncinate process: wraps around SMA + SMV. Carcinoma of head → obstructive jaundice (CBD obstruction) + GOO + portal vein invasion'],
    ['NECK','Overlies SMV/portal vein; short (2 cm)','SMV + splenic vein join POSTERIOR TO NECK → form portal vein; neck directly overlies this junction; surgical neck transection must avoid portal vein injury'],
    ['BODY','Crosses L1-L2; posterior to stomach (lesser sac)','Anterior: lesser sac (omental bursa), stomach. Posterior: aorta, SMA origin (acute angle = SMA syndrome risk), left renal vessels, left adrenal, splenic vein. In acute pancreatitis: inflammation tracks into lesser sac → pseudocysts here'],
    ['TAIL','Reaches left side; within splenorenal ligament + lienorenal ligament','In contact with splenic hilum + splenic vessels. ONLY INTRAPERITONEAL part. At risk during splenectomy. Tail contains highest density of islets of Langerhans.'],
])
doc.add_paragraph()

ah('Ductal System', level=2, color=(0x2E,0x75,0xB6))
at(['Duct','Details','Clinical Significance'],
[
    ['MAIN PANCREATIC DUCT (Wirsung)','Runs through entire length of pancreas; joins CBD at AMPULLA OF VATER; enters 2nd part of duodenum at major papilla (papilla of Vater); diameter 3-4 mm (head), 2-3 mm (body/tail)','Duct obstruction (gallstone at ampulla; tumour; fibrosis) → acute pancreatitis. >3 mm dilation on imaging = pathological (normal <3 mm). "Chain of lakes" = chronic pancreatitis.'],
    ['ACCESSORY DUCT (Santorini)','Drains head of pancreas; opens at MINOR PAPILLA (2 cm proximal to major papilla in D2)','PANCREAS DIVISUM: Wirsung + Santorini fail to fuse (most common congenital anomaly; 7-10% of population) → both ducts drain separately; Santorini at minor papilla → inadequate drainage → recurrent AP'],
    ['COMMON BILE DUCT (CBD)','Passes through or grooves posterior head of pancreas','Pancreatitis/pancreatic head cancer → CBD compression → obstructive jaundice. CBD + main pancreatic duct join to form hepatopancreatic ampulla (Vater).'],
    ['AMPULLA OF VATER + SPHINCTER OF ODDI','Junction of CBD + PD entering duodenum','Gallstone impaction at ampulla → biliary pancreatitis; Sphincter of Oddi dysfunction → recurrent pancreatitis; ERCP + sphincterotomy for obstruction'],
])
doc.add_paragraph()

ah('Blood Supply', level=2, color=(0x2E,0x75,0xB6))
at(['Region','Artery','Origin'],
[
    ['Head','SUPERIOR PANCREATICODUODENAL ARTERY (anterior + posterior branches)','Gastroduodenal artery (GDA) from common hepatic artery'],
    ['Head (inferior)','INFERIOR PANCREATICODUODENAL ARTERY','SMA (first branch)'],
    ['Body + Tail','SPLENIC ARTERY branches: dorsal pancreatic, transverse pancreatic, great pancreatic (arteria pancreatica magna), caudal pancreatic arteries','Splenic artery (from coeliac axis)'],
    ['IMPORTANT ANASTOMOSIS','Anterior + posterior pancreaticoduodenal arcades (superior + inferior anastomose) — protect duodenum during pancreatic head surgery','Dual blood supply = safe margin for Whipple resection'],
])
doc.add_paragraph()

ah('Lymphatics + Endocrine / Exocrine Functions', level=2, color=(0x2E,0x75,0xB6))
ab('Exocrine: Acinar cells → digestive enzymes (amylase, lipase, trypsinogen, chymotrypsinogen, elastase, phospholipase A2); ductal cells → bicarbonate-rich fluid (1-2 L/day). TOTAL daily pancreatic secretion: 1-2 litres (pH 7.5-8.5)')
ab('Endocrine: Islets of Langerhans: Alpha cells (glucagon); Beta cells (insulin); Delta cells (somatostatin); PP cells (pancreatic polypeptide)')
ab('Lymphatics: drain to pancreaticoduodenal, coeliac, superior mesenteric, para-aortic nodes')
doc.add_paragraph()

# ─── SECTION 2: DEFINITION + EPIDEMIOLOGY ───
ah('2. DEFINITION AND EPIDEMIOLOGY', level=1)
ap('ACUTE PANCREATITIS = an acute inflammatory process of the pancreas, with variable involvement of other regional tissues or remote organ systems, caused by premature intracellular activation of pancreatic digestive enzymes (primarily trypsinogen → trypsin), leading to autodigestion of the gland.', bold=True)
doc.add_paragraph()
ab('INCIDENCE: 20-40 per 100,000 population per year; one of the most common GI reasons for hospitalisation. Source: Sleisenger & Fordtran 11th Ed., p. 1062')
ab('279,145 annual admissions in USA (2014); 30-day readmission rate 14.3%')
ab('MORTALITY: Overall mortality has dropped from >10% to LESS THAN 2% in recent years (mild AP). Severe necrotising AP: still 15-30% mortality. Source: Sleisenger & Fordtran p. 1062')
ab('GALLSTONES are the dominant aetiology in Southern Europe; ALCOHOL dominant in Eastern Europe (Sleisenger p. 1062)')
doc.add_paragraph()

# ─── SECTION 3: AETIOLOGY ───
ah('3. AETIOLOGY', level=1)
ap('Mnemonic: "I GET SMASHED" — Idiopathic, Gallstones, Ethanol, Trauma, Steroids, Mumps/Malignancy, Autoimmune, Scorpion sting/Hypercalcaemia/Hyperlipidaemia, ERCP, Drugs', bold=True, color=(0xC0,0x00,0x00))
at(['Cause','Frequency','Key Facts'],
[
    ['GALLSTONES (biliary)','40-60% of cases','Most common cause overall. Small stones (<5 mm) more dangerous (OR 4-5); pass through cystic duct → ampullary obstruction. Gallstone pancreatitis MORE COMMON in women (gallstones more frequent). Cholecystectomy prevents recurrence. Source: Sleisenger p. 1064'],
    ['ALCOHOL (ethanol)','20-30%','2nd most common cause. Alcohol precipitates pancreatitis in only 5-10% of alcoholics — requires co-factors (genetic susceptibility, CFTR mutation, PRSS1/SPINK1 mutation). Mechanism: direct acinar cell toxicity + ductal protein plugs. Chronic alcohol → chronic pancreatitis.'],
    ['IDIOPATHIC','10-15%','Many are actually MICROLITHIASIS or biliary sludge on EUS (~40% of "idiopathic" AP have cholelithiasis/sludge on EUS). Source: Sleisenger p. 1065. Also genetic mutations (CFTR, PRSS1, SPINK1).'],
    ['HYPERTRIGLYCERIDAEMIA','2-9%','3rd most common identifiable cause. TG >1000 mg/dL (>11 mmol/L) precipitates AP. Serum may appear MILKY (lactescent). Amylase + lipase often normal or only mildly elevated (TG interferes with assay). Treat with insulin + IV lipid-lowering (plasmapheresis in severe cases). Source: Sleisenger p. 1068'],
    ['POST-ERCP','3-5%','Risk with therapeutic ERCP (sphincterotomy, manometry); rectal indomethacin reduces risk; periprocedural hydration reduces risk'],
    ['TRAUMA (abdominal)','~1-2%','Blunt abdominal trauma; steering wheel injury; pancreatic duct disruption'],
    ['DRUGS','1-2%','Azathioprine/6-MP (most common); Thiazides; Valproic acid; Tetracyclines; Sulfonamides; Furosemide; Oestrogens; Corticosteroids (rare)'],
    ['HYPERCALCAEMIA','<1%','Hyperparathyroidism; malignancy; sarcoidosis; Ca2+ activates trypsinogen → premature activation'],
    ['AUTOIMMUNE PANCREATITIS (AIP)','<1%','IgG4-related disease (Type 1 AIP) — responds to steroids; "sausage-shaped" pancreas on CT; elevated serum IgG4; IMPORTANT DIFFERENTIALS from pancreatic cancer'],
    ['INFECTION','<1%','Mumps (classic); Coxsackie B; Cytomegalovirus (HIV); Ascaris lumbricoides (India — ERCP + antihelminthic)'],
    ['DUCT OBSTRUCTION / STRUCTURAL','Variable','Pancreas divisum (most common congenital anomaly; 7-10%); annular pancreas; pancreatic tumours; ampullary adenoma; choledochal cyst'],
    ['GENETIC (hereditary pancreatitis)','Rare','PRSS1 gain-of-function mutation → trypsin over-activation; CFTR mutation; SPINK1 mutation; onset childhood; recurrent attacks; high risk of chronic pancreatitis + pancreatic cancer'],
    ['SCORPION STING','Rare in India/tropics','Tityus trinitatis venom directly stimulates pancreatic acinar cells'],
    ['VASCULAR (ischaemic)','Very rare','Post-cardiac surgery; vasculitis (PAN, SLE); atheroembolism'],
])
doc.add_paragraph()

# ─── SECTION 4: PATHOPHYSIOLOGY ───
ah('4. PATHOPHYSIOLOGY', level=1)
ap('The CENTRAL EVENT is PREMATURE INTRACELLULAR ACTIVATION of trypsinogen to trypsin within the pancreatic acinar cells — this triggers a cascade of enzyme activation → autodigestion.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()
at(['Step','Event','Consequence'],
[
    ['1. TRIGGER','Gallstone impaction at ampulla / Alcohol / Other causes → ductal hypertension OR direct acinar cell toxicity','Impaired secretion; colocalization of zymogen granules + lysosomes within acinar cells'],
    ['2. PREMATURE TRYPSINOGEN ACTIVATION','Lysosomal cathepsin B activates trypsinogen → TRYPSIN within the acinar cell','Trypsin activates all other zymogens: chymotrypsinogen, elastase, phospholipase A2, kallikrein, complement cascade'],
    ['3. ENZYME ACTIVATION CASCADE','Elastase → digests vessel walls → haemorrhage; Phospholipase A2 → digests cell membranes + lecithin in surfactant → pulmonary damage (ARDS); Lipase → fat necrosis; Kallikrein → bradykinin → vasodilation, increased vascular permeability, pain; Complement C3/C5a → inflammation','Local: pancreatic oedema, necrosis, haemorrhage, fat necrosis (white chalk marks = Ca2+ saponification of fat)'],
    ['4. LOCAL INFLAMMATION','Release of cytokines (IL-1, IL-6, TNF-alpha) from macrophages → local inflammatory response','Peripancreatic inflammation; fluid collections; paralytic ileus'],
    ['5. SYSTEMIC INFLAMMATORY RESPONSE (SIRS)','Cytokines enter systemic circulation → SIRS → MOF','SIRS criteria: temp >38 or <36; HR >90; RR >20; WBC >12,000 or <4,000'],
    ['6. ORGAN DYSFUNCTION (severe AP)','Lungs (ARDS — phospholipase A2 destroys surfactant); Kidneys (AKI — hypovolaemia + cytokines); Cardiovascular (shock — bradykinin + hypovolaemia); Coagulation (DIC); Brain (encephalopathy)','MULTIPLE ORGAN FAILURE = key determinant of mortality in severe AP'],
    ['7. LATE COMPLICATIONS','Pancreatic necrosis (sterile or infected); pseudocyst formation; pancreatic abscess; chronic pancreatitis (if recurrent)','Infected necrosis = most lethal complication; mortality 30-40%'],
])
doc.add_paragraph()
ap('FAT NECROSIS: Free fatty acids + calcium ions → calcium soponification (saponification) = white chalky deposits in mesentery, omentum, retroperitoneum — grossly visible at surgery/autopsy. Hypocalcaemia (Ca2+ sequestered in saponification) = poor prognostic sign.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

# ─── SECTION 5: CLINICAL FEATURES ───
ah('5. CLINICAL FEATURES', level=1)
ah('Symptoms', level=2, color=(0x2E,0x75,0xB6))
at(['Symptom','Details'],
[
    ['PAIN — CARDINAL SYMPTOM','SUDDEN onset SEVERE EPIGASTRIC/UPPER ABDOMINAL pain; RADIATES TO BACK ("boring through" pain); CONSTANT (not colicky); aggravated by movement; partially relieved by sitting forward (leaning forward/knee-chest position). Onset usually 12-24 hours after a large meal or alcohol binge.'],
    ['NAUSEA + VOMITING','Frequent, persistent vomiting; does NOT relieve pain (unlike biliary colic where vomiting may slightly relieve); may be projectile'],
    ['ABDOMINAL DISTENSION','Paralytic ileus (secondary to retroperitoneal inflammation); absent bowel sounds'],
    ['FEVER','Low-grade in mild AP (35-38.5°C); High fever + rigors = infected necrosis or cholangitis (ascending cholangitis — Charcot\'s triad)'],
    ['JAUNDICE','Transient in gallstone AP (CBD stone or oedema of head); Persistent → impacted CBD stone requiring ERCP'],
    ['ANOREXIA + DEHYDRATION','Reduced intake; significant third-space fluid losses → hypovolaemia'],
])
doc.add_paragraph()
ah('Signs', level=2, color=(0x2E,0x75,0xB6))
at(['Sign','Mechanism / Significance'],
[
    ['EPIGASTRIC TENDERNESS + GUARDING','Peritoneal irritation by enzyme-laden fluid; generalised peritonism if severe'],
    ['ABDOMINAL RIGIDITY','Severe pancreatitis with enzyme extravasation into peritoneal cavity'],
    ['REDUCED / ABSENT BOWEL SOUNDS','Paralytic ileus (retroperitoneal inflammation → reflex ileus)'],
    ['TACHYCARDIA + HYPOTENSION','Hypovolaemia (third-space losses into retroperitoneum + peritoneum + ileus) + SIRS; signs of shock'],
    ['FEVER (38-39°C)','Sterile SIRS (early); >39°C with rigors = infected necrosis (late — week 2-3)'],
    ['GREY TURNER\'S SIGN','Bruising/discolouration of FLANKS (left > right) — haemorrhagic pancreatitis; blood tracks along retroperitoneum to flanks. Takes 48-72 hours to develop.'],
    ['CULLEN\'S SIGN','Periumbilical ecchymosis (bruising around umbilicus) — haemorrhagic pancreatitis; blood tracks through lesser omentum/falciform ligament. Takes 48-72 hours.'],
    ['FOX\'S SIGN','Bruising over inguinal ligament — haemorrhagic pancreatitis (less well-known)'],
    ['JAUNDICE (scleral icterus)','CBD stone impaction; pancreatic head oedema compressing CBD'],
    ['PLEURAL EFFUSION (Left > bilateral)','Transdiaphragmatic spread of pancreatic enzymes; phospholipase A2 damages pleural membranes; amylase-rich pleural effusion'],
    ['PALPABLE MASS (epigastric)','Pseudocyst or inflammatory phlegmon — usually after 4-6 weeks'],
    ['TETANY (Chvostek + Trousseau)','Hypocalcaemia from fat saponification + reduced PTH response; calcium sequestration in fat necrosis'],
    ['ACUTE ABDOMEN','Severe AP may mimic bowel perforation — board-like rigidity; differentiated by serum amylase/lipase + CECT abdomen'],
])
doc.add_paragraph()

# ─── SECTION 6: INVESTIGATIONS ───
ah('6. INVESTIGATIONS', level=1)
ah('Blood Tests', level=2, color=(0x2E,0x75,0xB6))
at(['Test','Finding / Significance'],
[
    ['SERUM LIPASE (gold standard — enzyme diagnosis)','Elevated >3x ULN = diagnostic. More SENSITIVE (91%) and SPECIFIC than amylase. Remains elevated longer than amylase (7-10 days vs 3-4 days). PREFERRED investigation. Source: Sleisenger p. 1074'],
    ['SERUM AMYLASE','Elevated >3x ULN = diagnostic. Rises within 2-12 hours; returns to normal by 3-4 days. May be normal in: hypertriglyceridaemia pancreatitis; chronic pancreatitis (burnt-out gland); delayed presentation. NON-SPECIFIC: elevated in perforated DU, SMA ischaemia, ectopic pregnancy, parotitis, renal failure.'],
    ['ALT/AST (ALANINE AMINOTRANSFERASE)','ALT >150 U/L (or ≥3x ULN) within 48 hours strongly suggests BILIARY (GALLSTONE) pancreatitis (sensitivity 96%; predictive value). GGT ≥40 U/L + ALT ≥150 U/L + lipase ≥15x ULN = predict biliary cause. Source: Sleisenger p. 1065'],
    ['FBC','Elevated WBC (>10,000): SIRS; >15,000 = severe; >20,000 with fever = infected necrosis. Haematocrit elevated (haemoconcentration) — Hct >44% at admission = marker of severity (predictor of necrosis).'],
    ['SERUM CALCIUM','Hypocalcaemia (<2.0 mmol/L) = FAT NECROSIS sequestration; poor prognostic sign; Ranson criterion; severe AP'],
    ['SERUM GLUCOSE','Hyperglycaemia (>11 mmol/L or >200 mg/dL) = pancreatic endocrine dysfunction; Ranson criterion'],
    ['BLOOD UREA + CREATININE','Elevated: pre-renal uraemia (dehydration) + AKI (hepatorenal/inflammatory renal dysfunction)'],
    ['LDH (LACTIC DEHYDROGENASE)','Elevated (>350 IU/L at admission) = Ranson criterion; marker of tissue necrosis'],
    ['CRP (C-REACTIVE PROTEIN)','CRP >150 mg/L at 48 hours = SEVERE ACUTE PANCREATITIS (most widely used single serum marker of severity); validated marker; widely available. Peaks at 48-72 hours.'],
    ['SERUM TRIGLYCERIDES','Elevated (>1000 mg/dL) = hypertriglyceridaemia pancreatitis; amylase may be falsely normal in this setting'],
    ['ABG (ARTERIAL BLOOD GAS)','PaO2 <60 mmHg (<8 kPa) = ARDS / respiratory failure; one of Ranson criteria; modified Glasgow criterion'],
    ['PROCALCITONIN','Elevated >0.5-1.0 ng/mL = predicts infected necrosis; useful in late AP (>72 hours); better specificity than CRP for infection'],
    ['LFTs + BILIRUBIN','Elevated in biliary pancreatitis; persistent elevation → impacted CBD stone → urgent ERCP'],
    ['BLOOD CULTURES','If fever >38.5°C + elevated WBC → septicaemia; infected necrosis'],
])
doc.add_paragraph()
ah('Imaging', level=2, color=(0x2E,0x75,0xB6))
at(['Investigation','Findings / Role'],
[
    ['ULTRASOUND ABDOMEN (first-line, all patients)','IDENTIFIES GALLSTONES + BILIARY SLUDGE (aetiology); dilated CBD (>6 mm = stones); echogenic debris in GB; peri-pancreatic fluid. Pancreas often poorly visualised due to overlying bowel gas. Perform within 24 hours of admission.'],
    ['CONTRAST-ENHANCED CT ABDOMEN (CECT)\n— GOLD STANDARD for severity assessment','INDICATION: Uncertain diagnosis; failure to improve in 48-72 hours; suspected complications; before drainage/surgery. TIMING: NOT immediately (day 1); best at 72 hours+ (necrosis fully declared). FINDINGS: Pancreatic enlargement; peri-pancreatic fat stranding; fluid collections; pancreatic necrosis (non-enhancing areas = necrosis); gas in collections (infected necrosis); vascular complications'],
    ['MODIFIED CT SEVERITY INDEX (MCTSI / Balthazar Score)','CT grading of severity — see detailed table below'],
    ['MRI / MRCP','Best for duct anatomy; CBD stones not seen on USS; pancreas divisum; duct disruption; can differentiate pseudocyst vs WON without radiation; MRCP = non-invasive cholangiography; preferred when gadolinium safe'],
    ['ERCP (Endoscopic Retrograde Cholangiopancreatography)','NOT for diagnosis; THERAPEUTIC: urgent ERCP within 24-72 hours for: acute biliary pancreatitis + concurrent cholangitis (Charcot\'s triad) OR CBD stone with ongoing obstruction (bilirubin >3 mg/dL, not clearing within 24-48 hrs)'],
    ['ENDOSCOPIC ULTRASOUND (EUS)','Best for CBD microlithiasis/sludge; T-staging of ampullary tumours; drainage of pseudocysts/WON (endoscopic transmural drainage using EUS guidance)'],
    ['FNA / GUIDED ASPIRATION of collections','CT/EUS-guided FNA of suspected infected necrosis → Gram stain + culture; confirms infection → guides antibiotic therapy + timing of intervention'],
])
doc.add_paragraph()

# ─── SECTION 7: ATLANTA CLASSIFICATION ───
ah('7. 2012 ATLANTA CLASSIFICATION OF ACUTE PANCREATITIS (REVISED)', level=1)
ap('The Revised Atlanta Classification (2012) is the current standard for classifying severity of acute pancreatitis. Source: Sleisenger & Fordtran 11th Ed., Box 58.1, p. 1062.', bold=False, italic=True, color=(0x70,0x70,0x70), size=9)
at(['Category','Definition','Organ Failure','Local Complications','Mortality'],
[
    ['MILD ACUTE PANCREATITIS','No organ failure; no local or systemic complications. Self-limiting. 80% of all AP.','None','None (or resolving APFCs)','<1%; resolves within 1 week'],
    ['MODERATELY SEVERE ACUTE PANCREATITIS','Transient organ failure (<48 hours) AND/OR local or systemic complications WITHOUT persistent organ failure','Transient (<48 hrs) — single organ OR Multi-organ','Peripancreatic fluid collections; pancreatic/peripancreatic necrosis (sterile); exacerbation of pre-existing disease','<8%'],
    ['SEVERE ACUTE PANCREATITIS','Persistent organ failure (>48 hours) — single organ OR multi-organ failure','PERSISTENT (>48 hrs) — single organ OR Multi-organ','Pancreatic/peripancreatic necrosis (sterile or infected); infected necrosis = most lethal','15-30% (infected necrosis 30-40%)'],
])
doc.add_paragraph()
ap('KEY DISTINCTION: "Transient" vs "Persistent" organ failure (48-hour threshold) is the most important discriminator between moderately severe and severe AP.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Organ Failure Assessment — Modified Marshall Scoring System', level=2, color=(0x2E,0x75,0xB6))
at(['Organ System','Score 0','Score 1','Score 2','Score 3 (Organ Failure)'],
[
    ['RESPIRATORY (PaO2/FiO2)','> 400','301-400','201-300','< 200 = ORGAN FAILURE'],
    ['RENAL (Creatinine μmol/L)','< 134','134-169','170-310','> 310 = ORGAN FAILURE'],
    ['CARDIOVASCULAR (Systolic BP)','> 90 mmHg','< 90 mmHg (responsive to fluids)','< 90 mmHg (not responsive)','< 90 + pH < 7.3 = ORGAN FAILURE'],
])
ap('A score of ≥2 in ANY organ system = organ failure. Persistent organ failure = score ≥2 for >48 consecutive hours.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

# ─── SECTION 8: SEVERITY SCORING SYSTEMS ───
ah('8. SEVERITY SCORING SYSTEMS', level=1)
ap('EXAM HIGH YIELD: Know all 5 scoring systems. Ranson criteria and the Atlanta Classification are most commonly tested.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah("A. Ranson's Criteria (1974)", level=2, color=(0x2E,0x75,0xB6))
at(['At ADMISSION (5 parameters)','At 48 HOURS (6 parameters)'],
[
    ['Age > 55 years','Haematocrit FALL > 10%'],
    ['WBC > 16,000/mm³','BUN RISE > 5 mg/dL (>1.8 mmol/L)'],
    ['Blood glucose > 200 mg/dL (>11 mmol/L)','Serum CALCIUM < 8 mg/dL (<2.0 mmol/L)'],
    ['Serum LDH > 350 IU/L','PaO2 < 60 mmHg (<8 kPa)'],
    ['Serum AST > 250 U/L (Franson: >250 SF units)','Base DEFICIT > 4 mEq/L'],
    ['—','Estimated FLUID SEQUESTRATION > 6 litres'],
])
ap('SCORING: 0-2 = MILD (mortality <1%); 3-4 = MODERATE (mortality ~15%); 5-6 = SEVERE (mortality ~40%); 7-8 = CRITICAL (mortality ~100%)', bold=True, color=(0xC0,0x00,0x00))
ap('Limitation: Requires 48 hours to complete. Not applicable to gallstone pancreatitis (separate Ranson criteria for biliary AP — cut-offs differ). Cannot be used serially.', italic=True, size=9, color=(0x70,0x70,0x70))
doc.add_paragraph()

ah('B. Modified Glasgow (Imrie) Criteria', level=2, color=(0x2E,0x75,0xB6))
ap('Mnemonic: "PANCREAS" — 8 parameters assessed at 48 hours.', bold=True, color=(0x1F,0x4E,0x79))
at(['Parameter','Criterion for Adverse Score'],
[
    ['P — PaO2','< 60 mmHg (<8 kPa)'],
    ['A — Age','> 55 years'],
    ['N — Neutrophils (WBC)','> 15,000/mm³'],
    ['C — Calcium','< 2.0 mmol/L (<8 mg/dL)'],
    ['R — Renal (Urea/BUN)','> 16 mmol/L (>45 mg/dL)'],
    ['E — Enzymes (LDH, AST)','LDH > 600 IU/L OR AST/ALT > 200 IU/L'],
    ['A — Albumin','< 32 g/L'],
    ['S — Sugar (Glucose)','> 10 mmol/L (>180 mg/dL)'],
])
ap('SCORING: ≥3 parameters = SEVERE acute pancreatitis', bold=True, color=(0xC0,0x00,0x00))
ap('ADVANTAGE: Simple; quick; applicable to ALL causes (no separate gallstone criteria); assessed at 48 hours.', italic=True, size=9, color=(0x70,0x70,0x70))
doc.add_paragraph()

ah('C. BISAP Score (Bedside Index for Severity in Acute Pancreatitis)', level=2, color=(0x2E,0x75,0xB6))
ap('Mnemonic: "BUN Impaired Sensorium SIRS Age Pleural"', bold=True, color=(0x1F,0x4E,0x79))
at(['Parameter','Score 1 if Present'],
[
    ['B — BUN (Blood Urea Nitrogen)','> 25 mg/dL (>8.9 mmol/L)'],
    ['I — Impaired mental status','Any disorientation, lethargy, somnolence'],
    ['S — SIRS (≥2 of 4)','Temp <36 or >38°C; HR >90; RR >20; WBC <4,000 or >12,000'],
    ['A — Age','> 60 years'],
    ['P — Pleural effusion','Present on imaging'],
])
ap('SCORING: ≥3 = HIGH RISK of organ failure + in-hospital mortality. BISAP ≥3 = mortality 5.3%; BISAP 0 = mortality 0.2%. ADVANTAGE: Can be calculated at ADMISSION (within 24 hours) — earlier than Ranson.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('D. APACHE II Score', level=2, color=(0x2E,0x75,0xB6))
ab('12 physiological parameters + age + chronic health score; maximum score 71; >8 = severe AP')
ab('Advantage: Can be calculated DAILY (serial assessment); allows monitoring of treatment response')
ab('Disadvantage: Complex; requires multiple parameters; time-consuming to calculate')
ab('APACHE II >8 at admission = severe AP; >12 = very high mortality risk')
doc.add_paragraph()

ah('E. CT Severity Index (CTSI) — Balthazar + Modified (MCTSI)', level=2, color=(0x2E,0x75,0xB6))
ap('Assessed on CECT abdomen at 72 hours. Combines CT grade (A-E) + degree of necrosis.', bold=False)
at(['BALTHAZAR CT GRADE','Points','NECROSIS SCORE','Points'],
[
    ['Grade A: Normal pancreas','0','No necrosis','0'],
    ['Grade B: Focal/diffuse enlargement','1','< 30% necrosis','2'],
    ['Grade C: Peripancreatic fat stranding','2','30-50% necrosis','4'],
    ['Grade D: Single fluid collection','3','> 50% necrosis','6'],
    ['Grade E: ≥2 fluid collections OR gas','4','—','—'],
])
ap('CTSI = CT Grade score + Necrosis score (maximum = 10). CTSI 0-3 = mild; 4-6 = moderate; 7-10 = SEVERE. CTSI ≥4 = 15-20x more complications; necrosis >30% = high morbidity/mortality.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

# ─── SECTION 9: FLUID COLLECTIONS — ATLANTA 2012 DEFINITIONS ───
ah('9. FLUID COLLECTIONS IN ACUTE PANCREATITIS (REVISED ATLANTA 2012 DEFINITIONS)', level=1)
ap('CRITICAL TABLE — Examiner will ask you to differentiate these. Maingot\'s Abdominal Operations (Table 54-3) and Sleisenger p. 1062.', bold=True, color=(0xC0,0x00,0x00))
at(['Term','Time Post-AP','Content','Wall','Management'],
[
    ['ACUTE PERIPANCREATIC FLUID COLLECTION (APFC)','< 4 weeks (early)','Fluid only; no necrotic material; no solid debris','NO wall (no encapsulation)','Usually RESOLVE SPONTANEOUSLY (>50%); drain only if symptomatic or infected'],
    ['PANCREATIC PSEUDOCYST','> 4-6 weeks','Pancreatic secretions (amylase-rich fluid); NO solid debris or necrosis; develops after INTERSTITIAL pancreatitis (not necrotic AP)','Well-defined FIBROUS wall (encapsulated); requires ≥4 weeks to form','Most resolve spontaneously if <6 cm; drainage if symptomatic or >6 cm and not resolving (endoscopic transmural drainage preferred; EUS-guided; or surgical cyst-gastrostomy)'],
    ['ACUTE NECROTIC COLLECTION (ANC)','< 4 weeks','Mixed solid (necrotic) + fluid content; non-viable pancreatic/peripancreatic tissue','NO well-defined wall; heterogeneous content on CT','Intervention only if INFECTED (gas on CT = infected); Step-up approach: antibiotics (carbapenems) → percutaneous drainage → minimally invasive necrosectomy (VARD, endoscopic) → open necrosectomy if all fail'],
    ['WALLED-OFF NECROSIS (WON)','> 4 weeks','Necrotic (solid) + fluid content; liquefied over time; may contain debris','WELL-DEFINED FIBROUS wall (encapsulated) — "walled-off" over ≥4 weeks','As above; most important: EUS-guided transgastric/transduodenal drainage using LAMS (lumen-apposing metal stent) — preferred modern approach; Step-up approach'],
    ['INFECTED PANCREATIC NECROSIS','Usually > 2 weeks; peak 2-4 weeks','Infected ANC or WON; organisms: E. coli, Klebsiella, Enterococcus, Pseudomonas, Candida (superinfection)','+/- wall depending on timing','MOST LETHAL complication (30-40% mortality). Diagnostic: CT gas in collection ("mottled gas") or FNA (Gram stain + culture). Treatment: carbapenem antibiotics + STEP-UP approach (see Section 10)'],
    ['PANCREATIC ABSCESS','Rare; late (>4 weeks)','Pus collection; minimal necrosis; near pancreas','Fibrous wall','Surgical or percutaneous drainage; lower mortality than infected necrosis'],
])
ap('KEY DISTINCTION: Pseudocyst = NO necrosis + fluid only + develops AFTER interstitial (oedematous) AP. WON = HAS necrotic solid material + develops AFTER necrotising AP. Same CT appearance may look cystic, but WON cannot be treated by simple aspiration (solid debris + fibrin + necrosis). Source: Sleisenger p. 1063.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

# ─── SECTION 10: MANAGEMENT ───
ah('10. MANAGEMENT', level=1)
ap('Management follows three phases: (1) Initial resuscitation + monitoring; (2) Ongoing supportive care based on severity; (3) Treatment of complications + aetiology.', bold=True, color=(0x1F,0x4E,0x79))
doc.add_paragraph()

ah('A. INITIAL MANAGEMENT — FIRST 24 HOURS (All AP)', level=2, color=(0x2E,0x75,0xB6))
at(['Intervention','Detail'],
[
    ['AGGRESSIVE IV FLUID RESUSCITATION (MOST IMPORTANT)','Ringer\'s Lactate (RL) preferred over normal saline — reduces SIRS and systemic inflammation (WATERFALL RCT, 2022 supports RL). Rate: 250-500 mL/hour initially; 3-5 litres in first 12-24 hours; guide by urine output (target >0.5-1 mL/kg/hour), HR, blood pressure. AVOID both under-resuscitation (AKI risk) and over-resuscitation (abdominal compartment syndrome, pulmonary oedema risk). Early aggressive vs moderate hydration — latest guidelines support moderately aggressive (1.5-2 mL/kg/hour) rather than overly aggressive.'],
    ['URINE OUTPUT MONITORING','Urinary catheter; hourly urine output; target ≥0.5-1 mL/kg/hour'],
    ['ANALGESIA','IV morphine or IV hydromorphone (patient-controlled analgesia); NSAIDs if renal function adequate; epidural analgesia in severe cases. Avoid pethidine (meperidine) in renal failure. Adequate analgesia is a priority.'],
    ['NIL BY MOUTH (initial)','NPO initially for nausea + vomiting; NOT prolonged bowel rest (see nutrition section below)'],
    ['MONITORING','Continuous cardiac monitoring, SpO2, temperature, respiratory rate; ICU admission if organ failure'],
    ['OXYGEN','Supplemental O2; CPAP/NIV if PaO2 <60 mmHg; intubation + mechanical ventilation for ARDS'],
    ['BLOOD TESTS + IMAGING','Serum amylase/lipase; FBC; urea/creatinine/electrolytes; LFTs; glucose; calcium; CRP at baseline + 48 hours; ABG; USS abdomen (all patients within 24 hours)'],
    ['VTE PROPHYLAXIS','LMWH + TED stockings (high VTE risk in immobilised, critically ill patients)'],
])
doc.add_paragraph()

ah('B. NUTRITION (HIGH YIELD — recent change from old teaching)', level=2, color=(0x2E,0x75,0xB6))
ap('OLD TEACHING: "Rest the pancreas" — prolonged NPO + TPN. THIS IS NO LONGER CORRECT.', bold=True, color=(0xC0,0x00,0x00))
at(['Scenario','Recommendation','Evidence'],
[
    ['MILD AP','EARLY ORAL FEEDING within 24 hours as tolerated (low-fat, soft diet); NO need for NBM until enzymes normalise','AGA guidelines (11 RCTs): early feeding = shorter hospital stay; same or fewer complications. Sleisenger p. 2581.'],
    ['MODERATE-SEVERE AP (unable to eat ≥3-5 days)','ENTERAL NUTRITION preferred: nasogastric (NG) tube OR nasojejunal (NJ) tube feeding. NG and NJ EQUALLY EFFECTIVE (meta-analysis of 3 RCTs). Start within 24-72 hours if oral intake not possible.','AGA strong recommendation, moderate quality evidence: Enteral > TPN (reduces organ failure, infected necrosis, need for intervention). Source: Sleisenger p. 2582.'],
    ['PARENTERAL NUTRITION (TPN)','ONLY if enteral route is NOT POSSIBLE or NOT TOLERATED for prolonged period; associated with higher organ failure and infected necrosis rates vs enteral. Currently TPN = last resort.','Meta-analysis of 11 RCTs: TPN associated with increased harm (organ failure + infected necrosis) vs enteral or oral feeding. Sleisenger p. 2582.'],
    ['REFEEDING CRITERIA (mild AP)','Restart oral feeds when: pain improving + nausea resolving + amylase/lipase <3x ULN (caution: serum lipase >2.5x ULN associated with refeeding intolerance). Do NOT wait for complete normalisation of enzymes.','Sleisenger p. 2577.'],
])
doc.add_paragraph()

ah('C. ANTIBIOTICS — Use Only When Indicated', level=2, color=(0x2E,0x75,0xB6))
ap('PROPHYLACTIC ANTIBIOTICS ARE NOT RECOMMENDED in acute pancreatitis (including predicted severe AP).', bold=True, color=(0xC0,0x00,0x00))
at(['Indication','Antibiotic','Duration'],
[
    ['CONFIRMED INFECTED NECROSIS (CT gas + FNA +ve)','CARBAPENEM (Imipenem or Meropenem) — excellent pancreatic penetration OR Ciprofloxacin + Metronidazole (alternative)','Until definitive intervention (necrosectomy) + 7-14 days post-intervention; guided by cultures'],
    ['CONCURRENT CHOLANGITIS (biliary AP + Charcot\'s triad)','Piperacillin-tazobactam OR Ceftriaxone + Metronidazole; blood cultures first','Until ERCP performed + bile cultures sterilised; 5-7 days'],
    ['SUSPECTED INFECTED NECROSIS (clinical: fever + rising WBC > 2 weeks)','Start empirical Carbapenem; send FNA + blood cultures','Pending confirmation; adjust per culture results'],
    ['Note: PROPHYLACTIC antibiotics in sterile necrotising AP or severe AP WITHOUT evidence of infection — NOT indicated (multiple RCTs; no benefit; promotes resistant organisms)','—','—'],
])
doc.add_paragraph()

ah('D. BILIARY (GALLSTONE) PANCREATITIS — SPECIFIC MANAGEMENT', level=2, color=(0x2E,0x75,0xB6))
at(['Timing / Indication','Action'],
[
    ['Concurrent CHOLANGITIS (Charcot\'s triad: fever + jaundice + RUQ pain)','URGENT ERCP within 24 HOURS (life-saving) + sphincterotomy + stone extraction; antibiotics'],
    ['CBD stone WITHOUT cholangitis; persistent biliary obstruction (bilirubin >3 mg/dL not clearing in 24-48 hrs)','EARLY ERCP within 24-72 hours (NICE, ACG, AGA guidelines consensus); ERCP required to clear CBD before cholecystectomy'],
    ['MILD gallstone AP — CBD cleared / no cholangitis','CHOLECYSTECTOMY on SAME ADMISSION or within 2-4 weeks (NOT after discharge without cholecystectomy — high recurrence risk ~15-30% within 6 weeks)'],
    ['SEVERE gallstone AP with complications (necrosis)','Defer cholecystectomy until complications resolved (6-8 weeks); ERCP first if CBD stone suspected'],
    ['Rectal INDOMETHACIN (100 mg PR)','Give to ALL patients before/after ERCP — reduces risk of post-ERCP pancreatitis by ~50%'],
])
doc.add_paragraph()

ah('E. MANAGEMENT OF INFECTED PANCREATIC NECROSIS — "STEP-UP APPROACH"', level=2, color=(0x2E,0x75,0xB6))
ap('The STEP-UP APPROACH (PANTER trial, 2010) has replaced upfront open surgical necrosectomy for infected pancreatic necrosis. VITAL EXAM TOPIC.', bold=True, color=(0xC0,0x00,0x00))
at(['Step','Intervention','Indication / Notes'],
[
    ['STEP 1','IV ANTIBIOTICS (Carbapenems — Imipenem/Meropenem)','Start as soon as infected necrosis confirmed (CT gas or FNA +ve). Use for 2-4 weeks to control infection, delay intervention until necrosis "walled off" (≥4 weeks). Some patients respond to antibiotics alone (15-20%).'],
    ['STEP 2','PERCUTANEOUS CATHETER DRAINAGE (PCD)','CT or US-guided catheter drainage of infected ANC/WON; if NOT fully walled off yet; particularly fluid-predominant collections. Drains infection, reduces sepsis load. Success rate 30-60% without further intervention.'],
    ['STEP 3 (if PCD fails)','MINIMALLY INVASIVE NECROSECTOMY','(a) ENDOSCOPIC TRANSMURAL DRAINAGE + STEP-UP: EUS-guided cystogastrostomy + LAMS stent + endoscopic debridement (direct endoscopic necrosectomy, DEN) — PREFERRED if collection accessible transgastrically; (b) Video-Assisted Retroperitoneal Debridement (VARD) — laparoscopic approach through PCD tract in retroperitoneum; (c) Laparoscopic transgastric necrosectomy'],
    ['STEP 4 (if all above fail)','OPEN SURGICAL NECROSECTOMY','Open midline/bilateral subcostal laparotomy; wide debridement + removal of all necrotic tissue; closed cavity + irrigation (closed continuous irrigation) OR marsupialisation (open packing) + planned re-laparotomies. HIGH MORTALITY (25-40%). Reserved for failure of all minimally invasive steps.'],
])
ap('TIMING: "Wait" until necrosis is walled off (≥4 weeks after onset) before definitive intervention wherever possible — "STEP-UP, WAIT, MINIMALLY INVASIVE" is the modern paradigm. Immediate open surgery in early acute AP = very high mortality.', bold=True, color=(0x1F,0x4E,0x79))
doc.add_paragraph()

ah('F. PSEUDOCYST MANAGEMENT', level=2, color=(0x2E,0x75,0xB6))
at(['Scenario','Management'],
[
    ['Asymptomatic pseudocyst < 6 cm','Observe; serial USS or MRI; >50% resolve spontaneously within 6 weeks'],
    ['Symptomatic OR enlarging OR > 6 cm (not resolving)','DRAINAGE: (1) EUS-guided transmural drainage (cyst-gastrostomy / cyst-duodenostomy using LAMS) — PREFERRED if collection adjacent to stomach/duodenum; (2) Endoscopic transpapillary drainage via ERCP (if cyst communicates with MPD); (3) Percutaneous CT-guided drainage (for infected/inaccessible); (4) Surgical cyst-gastrostomy (internal drainage) — open or laparoscopic; now rarely needed.'],
    ['Complications: rupture (pancreatic ascites / pleural effusion)','ERCP + pancreatic duct stent; octreotide to reduce pancreatic secretion; surgical repair if ERCP fails'],
    ['Bleeding into pseudocyst (haemosuccus pancreaticus)','ARTERIAL EMBOLISATION (interventional radiology) of splenic/gastroduodenal/other pancreatic artery; emergency surgery if embolisation fails'],
])
doc.add_paragraph()

ah('G. COMPLICATIONS OF ACUTE PANCREATITIS', level=2, color=(0x2E,0x75,0xB6))
at(['Complication','Timing','Features + Management'],
[
    ['INFECTED PANCREATIC NECROSIS','> 2 weeks','Most lethal; 30-40% mortality; CT gas + FNA +ve; Step-up approach'],
    ['PSEUDOCYST','> 4-6 weeks','Palpable epigastric mass; most resolve; drain if symptomatic'],
    ['WALLED-OFF NECROSIS (WON)','> 4 weeks','Solid + fluid necrosis; EUS-guided drainage + DEN'],
    ['SPLENIC VEIN THROMBOSIS','Days-weeks','Sinistral (left-sided) portal hypertension; isolated gastric varices; splenomegaly; treat by splenectomy ± anticoagulation'],
    ['COLONIC NECROSIS','Days-weeks','Retroperitoneal inflammation → transverse colon ischaemia; severe complication; requires colectomy'],
    ['PANCREATIC DUCT DISRUPTION','Days-weeks','Pancreatic ascites (amylase-rich); pleural effusion; ERCP + duct stent; octreotide'],
    ['ABDOMINAL COMPARTMENT SYNDROME (ACS)','Days (severe AP)','Intra-abdominal pressure >20 mmHg + new organ failure; from massive retroperitoneal oedema + ileus + overzealous fluid resuscitation; decompressive laparotomy if refractory'],
    ['ARDS (ACUTE RESPIRATORY DISTRESS SYNDROME)','First week','Phospholipase A2 → surfactant destruction; PaO2 <60 mmHg; bilateral infiltrates on CXR; low PaO2/FiO2 ratio; ICU + mechanical ventilation; prone positioning for severe ARDS'],
    ['ACUTE KIDNEY INJURY (AKI)','First week','Hypovolaemia + cytokine-mediated vasoconstriction; fluid resuscitation; renal replacement therapy (CVVHF) if severe'],
    ['DIC (Disseminated Intravascular Coagulation)','Severe AP','Release of TF + activation of clotting; treat underlying cause + FFP + platelets'],
    ['LATE: CHRONIC PANCREATITIS','Months-years','Recurrent AP → fibrosis + exocrine/endocrine insufficiency (malabsorption + diabetes mellitus type 3c)'],
    ['LATE: PANCREATIC CANCER RISK','Long-term','Chronic pancreatitis from recurrent AP → 10-20x increased risk; hereditary pancreatitis highest risk'],
])
doc.add_paragraph()

# ─── SECTION 11: RECENT ADVANCES ───
ah('11. RECENT ADVANCES', level=1)
advances=[
    'STEP-UP APPROACH (PANTER trial, 2010; TENSION trial, 2022): Minimally invasive step-up approach for infected necrotising pancreatitis — reduces major complications and new-onset multi-organ failure compared to open necrosectomy (40% vs 69% complication rate). Endoscopic step-up (EUS + DEN) vs surgical step-up — TENSION trial: endoscopic approach reduced complications; now preferred where available.',
    'ENDOSCOPIC TRANSMURAL DRAINAGE + DIRECT ENDOSCOPIC NECROSECTOMY (DEN) with LAMS (Lumen-Apposing Metal Stent): EUS-guided LAMS creates direct cystogastrostomy; necrosome is debrided endoscopically through the stent access; avoids surgery entirely in many cases of WON.',
    'RINGER\'S LACTATE vs NORMAL SALINE for fluid resuscitation: WATERFALL RCT (NEJM 2022) — RL significantly reduced SIRS + organ failure vs NS; RL is now the preferred resuscitation fluid for acute pancreatitis.',
    'EARLY ORAL FEEDING: AGA guidelines (2018) based on 11 RCTs — early oral feeding (within 24 hours) for mild AP is safe and reduces hospital stay. Even severe AP benefits from early enteral nutrition (nasogastric = nasojejunal). Sleisenger p. 2580-2581.',
    'RECTAL INDOMETHACIN: 100 mg suppository before/after ERCP reduces post-ERCP pancreatitis risk by 50% (NEJM 2012); now ROUTINE practice for all high-risk ERCP.',
    'PLASMAPHERESIS for hypertriglyceridaemia pancreatitis: rapidly lowers serum TG; used in TG >1000 mg/dL with severe AP or failure of insulin infusion.',
    'ANTIBIOTICS: Multiple RCTs + meta-analyses confirm prophylactic antibiotics in severe/necrotising AP are NOT beneficial — do NOT use. Only for confirmed infection.',
    'ACUTE PERIPANCREATIC FLUID COLLECTION (APFC) vs PSEUDOCYST vs WON: Revised Atlanta 2012 terminology has standardised these definitions — essential for clinical communication and management decisions.',
    'ENDOSCOPIC PAPILLARY LARGE BALLOON DILATION (EPLBD): For large CBD stones in gallstone pancreatitis — alternative to surgery for bile duct clearance, avoiding need for surgical CBD exploration.',
    'MICROBIOME IN AP: Gut dysbiosis + bacterial translocation contributes to infected necrosis — probiotics NOT recommended (PROPATRIA trial: harmful in severe AP — increased mortality with probiotics). Selective gut decontamination + prebiotics under investigation.',
]
for a in advances: ab(a)
doc.add_paragraph()

# ─── SECTION 12: SCORING GUIDE ───
ah("12. EXAMINER'S SCORING GUIDE — 30 Marks", level=1)
at(['Section','Marks'],
[
    ['Pancreatic anatomy (parts + ductal system + blood supply + relations)','4'],
    ['Definition + aetiology (I GET SMASHED mnemonic + details)','3'],
    ['Pathophysiology (trypsin activation → enzyme cascade → SIRS → MOF)','3'],
    ['Clinical features (symptoms + signs including Grey Turner\'s + Cullen\'s)','3'],
    ['Investigations (lipase vs amylase; CRP; USS; CECT; ERCP indications)','3'],
    ['Severity assessment: Atlanta 2012 + Ranson + Glasgow + BISAP + CTSI tables','5'],
    ['Management: fluid resuscitation (RL) + nutrition (early oral/enteral > TPN) + antibiotics (only for infection) + biliary AP (ERCP + cholecystectomy)','5'],
    ['Complications: infected necrosis (Step-up approach) + pseudocyst + WON (Atlanta 2012 definitions)','3'],
    ['Recent advances','1'],
    ['TOTAL','30'],
])
doc.add_paragraph()

ah('Sharp-Edge Discriminators — Mark-Winners', level=2, color=(0x2E,0x75,0xB6))
tips=[
    'Gallstones 40-60%; Alcohol 20-30%; Hypertriglyceridaemia 3rd most common (TG >1000 mg/dL). Source: Sleisenger p. 1064-1068.',
    'LIPASE more sensitive (91%) + specific than amylase; remains elevated 7-10 days vs amylase 3-4 days. Source: Sleisenger p. 1074.',
    'ALT >150 U/L within 48 hours = strong predictor of BILIARY (gallstone) aetiology.',
    'CRP >150 mg/L at 48 hours = SEVERE AP marker — most widely used serum severity test.',
    'GREY TURNER\'S SIGN = flank bruising (RETROPERITONEAL haemorrhage); CULLEN\'S SIGN = umbilical bruising (lesser omentum tracking).',
    'TRANSIENT vs PERSISTENT organ failure (48-hour threshold) = Moderately severe vs SEVERE AP (Revised Atlanta 2012). Source: Sleisenger Box 58.1 p. 1062.',
    'RANSON: 5 criteria at admission + 6 at 48 hours; ≥3 = severe; ≥5 = high mortality.',
    'GLASGOW (PANCREAS mnemonic): 8 criteria at 48 hours; ≥3 = severe.',
    'BISAP: 5 criteria at admission; ≥3 = severe; calculated within 24 hours (earlier than Ranson).',
    'CTSI ≥7/10 = severe CT finding; GAS in collection on CT = infected necrosis until proven otherwise.',
    'PSEUDOCYST = NO necrosis; FLUID ONLY; FIBROUS WALL; after INTERSTITIAL AP. WON = HAS NECROTIC SOLID MATERIAL; after NECROTISING AP.',
    'EARLY FEEDING (within 24 hours) for mild AP is now standard — AGA strong recommendation (11 RCTs). Enteral > TPN. NG = NJ equally effective. Source: Sleisenger p. 2580-2582.',
    'PROPHYLACTIC ANTIBIOTICS NOT recommended in AP (even necrotising, unless infected) — multiple RCTs show no benefit + promotes resistant organisms.',
    'URGENT ERCP within 24 hours for biliary AP + cholangitis (Charcot\'s triad); ERCP within 24-72 hours for CBD stone without cholangitis.',
    'CHOLECYSTECTOMY SAME ADMISSION (or within 2-4 weeks) for mild biliary AP — reduces recurrence risk (15-30% in 6 weeks if not done).',
    'STEP-UP APPROACH for infected necrosis: Antibiotics → PCD → Minimally invasive necrosectomy (EUS/VARD) → Open surgery. PANTER trial 2010 + TENSION trial 2022.',
    'RINGER\'S LACTATE preferred over normal saline for resuscitation — WATERFALL RCT (NEJM 2022): RL reduces SIRS + organ failure.',
    'RECTAL INDOMETHACIN 100 mg before/after ERCP = ROUTINE practice — reduces post-ERCP pancreatitis 50%.',
    'HAEMOSUCCUS PANCREATICUS = bleeding into pseudocyst or pseudoaneurysm of splenic/gastroduodenal artery; treat with interventional radiology embolisation first.',
    'Abdominal compartment syndrome: intra-abdominal pressure >20 mmHg + new organ failure in severe AP; decompressive laparotomy if refractory.',
]
for t in tips: ab(t)
doc.add_paragraph()
ps=doc.add_paragraph()
rs=ps.add_run("Sources: Sleisenger & Fordtran's Gastrointestinal and Liver Disease 11th Ed. (Ch. 58, p. 1062-1090) | Bailey & Love's Short Practice of Surgery 28th Ed. | Maingot's Abdominal Operations (Table 54-3) | Current Surgical Therapy 14e | Schwartz's Principles of Surgery 11th Ed. | AGA Technical Review on Acute Pancreatitis (2018) | ACG Clinical Guideline (2013) | IAP/APA Guidelines (2013)")
rs.italic=True; rs.font.size=Pt(9); rs.font.color.rgb=RGBColor(0x70,0x70,0x70)

out='/tmp/workspace/ms-surgery-notes/Acute_Pancreatitis_30marks.docx'
doc.save(out)
print(f'Saved: {out}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()
sec = doc.sections[0]
sec.top_margin = Cm(2); sec.bottom_margin = Cm(2)
sec.left_margin = Cm(2.5); sec.right_margin = Cm(2.5)
doc.styles['Normal'].font.name = 'Arial'
doc.styles['Normal'].font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def ah(text, level=1, color=(0x1F,0x4E,0x79)):
    p = doc.add_heading(text, level=level)
    for r in p.runs: r.font.color.rgb = RGBColor(*color)
    return p

def ap(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    r = p.add_run(text); r.bold=bold; r.italic=italic; r.font.size=Pt(size)
    if color: r.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def ab(text, bold=False):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    r = p.add_run(text); r.font.size=Pt(11); r.bold=bold
    return p

def scbg(cell, hx):
    tc=cell._tc; tcPr=tc.get_or_add_tcPr()
    shd=OxmlElement('w:shd')
    shd.set(qn('w:val'),'clear'); shd.set(qn('w:color'),'auto')
    shd.set(qn('w:fill'),hx); tcPr.append(shd)

def at(headers, rows, hc='1F4E79', arc='D6E4F0'):
    tbl=doc.add_table(rows=1+len(rows), cols=len(headers))
    tbl.style='Table Grid'
    hr=tbl.rows[0].cells
    for i,h in enumerate(headers):
        hr[i].text=h; scbg(hr[i],hc)
        for p in hr[i].paragraphs:
            for r in p.runs:
                r.bold=True; r.font.size=Pt(10); r.font.color.rgb=RGBColor(0xFF,0xFF,0xFF)
    for ri,rd in enumerate(rows):
        cs=tbl.rows[ri+1].cells
        for ci,txt in enumerate(rd):
            cs[ci].text=txt
            for p in cs[ci].paragraphs:
                for r in p.runs: r.font.size=Pt(10)
        if ri%2==0:
            for c in cs: scbg(c,arc)
    return tbl

def embed_img(url, path, w=Inches(5.5), cap=None):
    try:
        r=requests.get(url,timeout=15)
        if r.status_code==200:
            with open(path,'wb') as f: f.write(r.content)
            doc.add_picture(path,width=w)
            doc.paragraphs[-1].alignment=WD_ALIGN_PARAGRAPH.CENTER
            if cap:
                c=doc.add_paragraph(cap); c.alignment=WD_ALIGN_PARAGRAPH.CENTER
                c.runs[0].italic=True; c.runs[0].font.size=Pt(9)
    except:
        ap(f'[Image: {cap}]',italic=True,color=(0x70,0x70,0x70))

# ─── COVER ───
p=doc.add_paragraph(); p.alignment=WD_ALIGN_PARAGRAPH.CENTER
r=p.add_run('MS GENERAL SURGERY — EXAM NOTES')
r.bold=True; r.font.size=Pt(18); r.font.color.rgb=RGBColor(0x1F,0x4E,0x79)
p2=doc.add_paragraph(); p2.alignment=WD_ALIGN_PARAGRAPH.CENTER
r2=p2.add_run('Obstructive Jaundice — 30-Mark Question')
r2.bold=True; r2.font.size=Pt(14); r2.font.color.rgb=RGBColor(0x2E,0x75,0xB6)
p3=doc.add_paragraph(); p3.alignment=WD_ALIGN_PARAGRAPH.CENTER
r3=p3.add_run("Sources: Bailey & Love 28th Ed. | Fischer's Mastery 8th Ed. | Sabiston 21st Ed. | Yamada's 7th Ed. | Current Surgical Therapy 14e | Schwartz's 11th Ed.")
r3.italic=True; r3.font.size=Pt(10); r3.font.color.rgb=RGBColor(0x70,0x70,0x70)
doc.add_paragraph()
pq=doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Classify obstructive jaundice. Describe its causes, pathophysiology, clinical features, investigations and management including ERCP and surgical options."   [30 Marks]').bold=True
pq.runs[0].font.size=Pt(11); pq.runs[0].font.color.rgb=RGBColor(0x7B,0x22,0x00)
doc.add_paragraph()

embed_img(
    'https://cdn.orris.care/cdss_images/roco_radiology_ROCO_40423_1766648367213.png',
    '/tmp/workspace/ms-surgery-notes/ercp_obstruction.jpg', w=Inches(5.2),
    cap='Figure 1: ERCP fluoroscopy — Obstructive jaundice with malignant biliary stricture. White arrow: abrupt "cut-off" sign at mid CBD — pathognomonic of malignant obstruction (cholangiocarcinoma/pancreatic head cancer). Proximal intrahepatic bile ducts are markedly dilated. Guidewire in situ for stent placement. (Fischer\'s Mastery / PMC)'
)
embed_img(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_a754f39c5fe7f9608b2d07153e6f62bf82d7fdf0f74dc6a8e646c56b464a250f.jpg',
    '/tmp/workspace/ms-surgery-notes/ercp_stent.jpg', w=Inches(5.2),
    cap='Figure 2: ERCP — Biliary stent in situ across a proximal CBD stricture. Proximal intrahepatic ductal dilatation is clearly demonstrated. 10Fr pigtail plastic stent deployed for biliary drainage.'
)
doc.add_paragraph()

# ─── SECTION 1: ANATOMY ───
ah('1. SURGICAL ANATOMY OF THE BILIARY SYSTEM', level=1)
ap('EXAM TIP: Draw the extrahepatic biliary tree including Calot\'s triangle, Couinaud segments, and CBD relations — scores 3-4 marks.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Liver — Couinaud Segmental Anatomy', level=2, color=(0x2E,0x75,0xB6))
ap('The Couinaud classification divides the liver into 8 independent functional segments, each with its own portal venous branch, hepatic arterial supply, and biliary drainage. Source: Bailey & Love 28th Ed., Fig. 88.2.', italic=True, color=(0x70,0x70,0x70), size=9)
at(['Segment','Location','Hepatic Duct Drainage'],
[
    ['I — Caudate lobe','Posterior; drains directly into IVC; SPARED in Budd-Chiari','Drains independently into both right and left hepatic ducts'],
    ['II, III — Left lateral section','Left lobe (lateral)','Left hepatic duct (segment II + III)'],
    ['IV — Left medial section (quadrate lobe)','Left lobe (medial); between falciform + left hepatic fissure','Left hepatic duct; segment IVa (superior) + IVb (inferior)'],
    ['V, VI — Right anterior + posterior (inferior)','Right lobe (inferior)','Right hepatic duct (anterior + posterior sectoral ducts)'],
    ['VII, VIII — Right anterior + posterior (superior)','Right lobe (superior)','Right hepatic duct'],
    ['NOTE: Bismuth classification of hilar cholangiocarcinoma uses Couinaud segments to define extent of resection required','',''],
])
doc.add_paragraph()

ah('Extrahepatic Biliary Tree', level=2, color=(0x2E,0x75,0xB6))
at(['Structure','Details','Clinical Significance'],
[
    ['RIGHT HEPATIC DUCT','Formed by union of right anterior (V+VIII) and right posterior (VI+VII) sectoral ducts; short (0.5-1 cm)','Short length = less room for reconstruction; Bismuth II-IV hilar tumours need right hepatectomy'],
    ['LEFT HEPATIC DUCT','Longer (2-4 cm); runs horizontally in umbilical fissure','More accessible for biliary-enteric anastomosis (longer extrahepatic course)'],
    ['COMMON HEPATIC DUCT (CHD)','Union of right + left hepatic ducts at PORTA HEPATIS (hilar plate); length 2-4 cm; diameter 4-6 mm (normal)','Dilated CHD (>6 mm) = biliary obstruction on USS; Bismuth type I cholangiocarcinoma involves CHD below confluence'],
    ['CYSTIC DUCT','Gallbladder neck → joins CHD to form CBD; length 2-4 cm; spiral valves of Heister inside','Cystic duct obstruction = acute cholecystitis. Stones may impact here → Mirizzi syndrome (external compression of CHD by stone in cystic duct or Hartmann\'s pouch)'],
    ['COMMON BILE DUCT (CBD)','Union of CHD + cystic duct; length 6-8 cm; normal diameter <6 mm (or ≤8 mm if post-cholecystectomy)','Four parts: Supraduodenal (hepatoduodenal ligament — posterior, medial to hepatic artery and anterior to portal vein); Retroduodenal; Pancreatic (grooves/passes through pancreatic head); Intraduodenal (papillary/ampullary segment)'],
    ['AMPULLA OF VATER','CBD + main pancreatic duct (Wirsung) join → enter D2 at major papilla (papilla of Vater)','Ampullary carcinoma = resectable, BEST prognosis of all periampullary cancers (5-yr survival 50-60%). Gallstone impaction = biliary pancreatitis + obstructive jaundice.'],
    ['SPHINCTER OF ODDI','Smooth muscle sphincter surrounding ampulla; controls bile + pancreatic juice flow','Sphincter of Oddi dysfunction → recurrent pancreatitis/biliary colic; treat with ERCP + sphincterotomy'],
])
doc.add_paragraph()

ah("Calot's Triangle (Cystohepatic Triangle) — HIGH YIELD", level=2, color=(0x2E,0x75,0xB6))
ap('Source: Fischer\'s Mastery of Surgery 8th Ed., p. 4554-4555.', italic=True, color=(0x70,0x70,0x70), size=9)
at(['Boundary','Structure'],
[
    ['SUPERIOR / ROOF','Visceral surface of liver (undersurface of right lobe)'],
    ['MEDIAL','Common hepatic duct'],
    ['INFERIOR (floor)','Cystic duct'],
    ['CONTENTS of Calot\'s Triangle','CYSTIC ARTERY (branch of RIGHT HEPATIC ARTERY, usually); NODE OF CALOT (Lund\'s node — enlarged in cholecystitis + gallbladder cancer); RIGHT HEPATIC ARTERY (passes behind CHD usually); accessory bile ducts (common variants)'],
    ['CRITICAL VIEW OF SAFETY (CVS)','Laparoscopic cholecystectomy: the cystic plate must be cleared; only two structures (cystic duct + cystic artery) should enter the gallbladder — before any clipping/division. Prevents bile duct injury.'],
])
ap('Cystic artery: typically branch of right hepatic artery; but can arise from left hepatic, common hepatic, GDA, or SMA — ALWAYS verify in Calot\'s triangle. Double cystic arteries occur in ~25% of patients. Source: Fischer\'s p. 4550, 4554.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Blood Supply of the CBD', level=2, color=(0x2E,0x75,0xB6))
ab('CBD has an AXIAL blood supply running at 3 o\'clock and 9 o\'clock positions along the duct wall (like a ladder)')
ab('UPPER CBD: supplied from ABOVE by RIGHT HEPATIC ARTERY + branches from cystic artery')
ab('LOWER CBD: supplied from BELOW by GASTRODUODENAL ARTERY + retroduodenal branches')
ab('IMPORTANT: Bile duct INJURY during cholecystectomy → ischaemic stricture (if 3 o\'clock + 9 o\'clock vessels divided). Dissection too close to CBD → devascularisation → late biliary stricture')
ab('HIGH BILE DUCT INJURIES (hepatic hilum) = worse prognosis because of poorer blood supply to hilar region')
doc.add_paragraph()

# ─── SECTION 2: DEFINITION ───
ah('2. DEFINITION', level=1)
ap('OBSTRUCTIVE JAUNDICE (Surgical Jaundice / Post-hepatic Jaundice / Cholestatic Jaundice) = jaundice resulting from mechanical obstruction to the flow of bile from the liver to the duodenum, causing conjugated (direct) hyperbilirubinaemia.', bold=True)
doc.add_paragraph()
ab('Normal total serum bilirubin: 3-17 μmol/L (0.2-1.0 mg/dL)')
ab('Clinical jaundice (icterus) becomes visible when serum bilirubin >34-51 μmol/L (2-3 mg/dL)')
ab('In obstructive jaundice: predominant CONJUGATED (direct) hyperbilirubinaemia (>50% direct fraction)')
ab('Bile cannot reach duodenum → backs up into liver → regurgitates into bloodstream → conjugated bilirubin excreted in urine (dark urine = bilirubinuria) + absent urobilinogen in urine + pale stools (acholuric/clay-coloured stool = absence of stercobilinogen)')
doc.add_paragraph()

# ─── SECTION 3: CLASSIFICATION OF JAUNDICE ───
ah('3. CLASSIFICATION OF JAUNDICE', level=1)
ap('FULL CLASSIFICATION of all types of jaundice must be written — examiner expects this before obstructive jaundice specifically.', bold=True, color=(0xC0,0x00,0x00))
at(['Type','Bilirubin Fraction','Urine Bilirubin','Urine Urobilinogen','Stools','Mechanism'],
[
    ['PRE-HEPATIC (Haemolytic)','UNCONJUGATED (indirect) ↑','ABSENT (unconjugated not water-soluble → not filtered by kidney)','↑ Increased (excess bilirubin → urobilinogen)','Normal (or dark)','Excess RBC destruction → unconjugated bilirubin overload exceeds hepatic conjugation capacity. Causes: haemolytic anaemia, sickle cell, G6PD deficiency, malaria, haemolytic transfusion reaction'],
    ['HEPATOCELLULAR (Hepatic)','MIXED (conjugated + unconjugated) ↑','PRESENT (conjugated bilirubin leaks back)','↑ or ↓ variable','Pale (variable)','Hepatocyte damage → failure of uptake, conjugation AND excretion. Causes: viral hepatitis (A/B/C/E), alcoholic hepatitis, drugs (isoniazid, paracetamol toxicity), autoimmune hepatitis, Wilson\'s disease, haemochromatosis, sepsis'],
    ['POST-HEPATIC (Obstructive / Cholestatic)','CONJUGATED (direct) ↑','PRESENT (dark urine = bilirubinuria; "Coca-Cola" / "tea-coloured" urine)','ABSENT (urobilinogen absent — bile cannot reach intestine)','PALE / CLAY-COLOURED (acholuric — no stercobilinogen formed)','Mechanical obstruction to bile flow → conjugated bilirubin regurgitates into blood. MAIN TOPIC OF THIS ANSWER.'],
])
doc.add_paragraph()

# ─── SECTION 4: CAUSES ───
ah('4. CAUSES OF OBSTRUCTIVE JAUNDICE', level=1)
ap('Classification by SITE of obstruction: (1) Within the lumen; (2) In the wall of the duct; (3) Outside the duct (extrinsic compression). Also classified as BENIGN vs MALIGNANT.', bold=True, color=(0x1F,0x4E,0x79))
at(['Site / Category','Cause'],
[
    ['INTRALUMINAL (Within the Duct Lumen)','CHOLEDOCHOLITHIASIS (CBD stone) — MOST COMMON BENIGN cause worldwide; Parasites (Ascaris lumbricoides — biliary ascariasis, common in India; Clonorchis sinensis; Fasciola hepatica; Echinococcus daughter cysts into CBD); Haemobilia (blood clot in CBD — trauma, aneurysm, iatrogenic); Biliary sludge'],
    ['MURAL (In the Wall of the Duct — INTRINSIC)','CHOLANGIOCARCINOMA (bile duct cancer) — most common malignant intrinsic cause; Primary Sclerosing Cholangitis (PSC) — inflammatory strictures + multifocal; Biliary stricture — post-operative (most common: after laparoscopic cholecystectomy; after Whipple\'s; after liver transplant); Ampullary carcinoma (at papilla of Vater); Primary biliary cholangitis (PBC); Choledochal cyst; Haemobilia'],
    ['EXTRAMURAL (Extrinsic Compression of the Duct)','CARCINOMA OF HEAD OF PANCREAS — MOST COMMON MALIGNANT cause overall; Periampullary carcinoma; Carcinoid tumour; Mirizzi syndrome (stone in cystic duct / Hartmann\'s pouch externally compresses CHD); Pancreatitis (acute — oedema; chronic — fibrous stricture); Lymph nodes (metastatic adenopathy — breast, colon, lymphoma, gastric cancer); Portal biliopathy (portal cavernoma — enlarged periportal collaterals compress CBD in extrahepatic portal vein obstruction — common in INDIA); Duodenal carcinoma; Retroperitoneal fibrosis'],
    ['INTRAHEPATIC CHOLESTASIS (may mimic obstructive)','Primary biliary cholangitis (PBC — AMA +ve; affects interlobular bile ducts); Primary sclerosing cholangitis (PSC — multifocal); Drug-induced cholestasis (OCP, chlorpromazine, erythromycin); Sepsis-associated cholestasis; Benign recurrent intrahepatic cholestasis; Intrahepatic cholangiocarcinoma; Hepatocellular carcinoma compressing bile ducts; Liver metastases'],
    ['INDIA-SPECIFIC','Ascaris lumbricoides (biliary ascariasis) — common cause of biliary obstruction in rural India; Portal biliopathy in EHPVO (children); TB (tuberculoma compressing CBD / porta hepatis nodes)'],
])
doc.add_paragraph()

ah('Periampullary Tumours — The Four Causes of Painless Obstructive Jaundice', level=2, color=(0x2E,0x75,0xB6))
at(['Tumour','Origin','Proportion of Periampullary Cancers','5-Year Survival after Whipple\'s'],
[
    ['CARCINOMA HEAD OF PANCREAS','Ductal epithelium of pancreatic head','~65-70%','15-20% (worst prognosis)'],
    ['AMPULLARY CARCINOMA (Carcinoma of Ampulla of Vater)','Ampullary epithelium (at papilla)','~10-15%','50-60% (BEST prognosis of all four)'],
    ['DISTAL CHOLANGIOCARCINOMA (Klatskin tumour if hilar)','Bile duct epithelium','~10%','25-40%'],
    ['DUODENAL CARCINOMA','Duodenal mucosa (D2)','~5%','40-50%'],
])
ap('Mnemonic "PACD" — Pancreatic, Ampullary, Cholangiocarcinoma, Duodenal. ALL four cause obstructive jaundice. ALL four are potentially resectable by Whipple\'s pancreaticoduodenectomy (distal CBD cholangiocarcinoma and duodenal carcinoma) or partial hepatectomy (hilar cholangiocarcinoma).', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Bismuth-Corlette Classification of Hilar Cholangiocarcinoma (Klatskin Tumour)', level=2, color=(0x2E,0x75,0xB6))
at(['Type','Description','Resection Required'],
[
    ['Type I','Below confluence; involves CHD only','CBD resection + Roux-en-Y hepaticojejunostomy'],
    ['Type II','Involves CONFLUENCE (hilar plate) — affects both right and left hepatic duct origins','Biliary confluence resection + hepaticojejunostomy (bilateral duct anastomosis)'],
    ['Type IIIa','Extends into RIGHT hepatic duct','Right hepatectomy + caudate lobectomy + biliary reconstruction'],
    ['Type IIIb','Extends into LEFT hepatic duct','Left hepatectomy + caudate lobectomy + biliary reconstruction'],
    ['Type IV','Involves BOTH right and left hepatic ducts (multifocal / bilateral)','Often UNRESECTABLE; consider liver transplantation for selected Type IV in specialised centres'],
])
doc.add_paragraph()

# ─── SECTION 5: PATHOPHYSIOLOGY ───
ah('5. PATHOPHYSIOLOGY OF OBSTRUCTIVE JAUNDICE', level=1)
at(['Event','Mechanism','Clinical / Lab Consequence'],
[
    ['BILE FLOW OBSTRUCTION','Mechanical block → bile backs up → intrahepatic biliary pressure rises → hepatocyte damage → bilirubin regurgitates into systemic circulation','Conjugated hyperbilirubinaemia; raised serum bilirubin'],
    ['CONJUGATED BILIRUBINAEMIA','Water-soluble conjugated bilirubin → excreted in urine','DARK URINE (bilirubinuria = "Coca-Cola" / "tea-coloured")'],
    ['ABSENT BILE IN INTESTINE','No stercobilinogen formed; no urobilinogen reabsorbed','PALE / CLAY-COLOURED STOOLS; ABSENT urinary urobilinogen'],
    ['FAT MALABSORPTION','Bile salts absent → fat-soluble vitamins (A, D, E, K) not absorbed; fat malabsorption → steatorrhoea','Vitamin K deficiency → prolonged PT/INR → COAGULOPATHY (bleeding risk; GIVE VITAMIN K before surgery); Vitamin D deficiency → metabolic bone disease (chronic); Vitamin A → night blindness; Steatorrhoea'],
    ['BILE SALTS IN BLOOD','Bile salts accumulate in skin → stimulate dermal nerve fibres','PRURITUS (intense itching) — often precedes visible jaundice; treated with cholestyramine, rifampicin, antihistamines'],
    ['HEPATIC DYSFUNCTION (prolonged)','Back-pressure → hepatocyte necrosis; impaired hepatic synthetic function','Raised ALP (most sensitive early marker); raised GGT; raised bilirubin; later: low albumin; prolonged PT'],
    ['RENAL IMPAIRMENT (Hepatorenal physiology)','Conjugated bilirubin + bile acids deposit in renal tubules → tubular injury; reduced GFR; ENDOTOXAEMIA (gut bacterial translocation due to absent gut bile acids → impaired gut mucosal immunity + reduced immunoglobulin A) → bacteraemia → sepsis → AKI','Pre-operative urine output monitoring; CAREFUL FLUID BALANCE; avoid nephrotoxic agents; PERCUTANEOUS BILIARY DRAINAGE before surgery in severe obstructive jaundice (jaundice >200 μmol/L)'],
    ['COAGULOPATHY','Vitamin K malabsorption → reduced synthesis of factors II, VII, IX, X → prolonged PT/INR','IV VITAMIN K 10 mg daily × 3 days before surgery; FFP if emergency. PT should return to normal within 48-72 hours if obstruction is relieved or Vit K given.'],
    ['INFECTION — ASCENDING CHOLANGITIS','Biliary stasis → bacterial colonisation of bile → ascending infection up bile duct → Charcot\'s triad + Reynold\'s pentad','SEPTICAEMIA; gram-negative bacteraemia (E. coli, Klebsiella, Enterococcus, Pseudomonas)'],
    ['SECONDARY BILIARY CIRRHOSIS','Chronic obstruction (months-years) → periportal fibrosis → biliary cirrhosis → portal hypertension','Rare in modern practice (early diagnosis + drainage prevents this)'],
])
doc.add_paragraph()

# ─── SECTION 6: CLINICAL FEATURES ───
ah('6. CLINICAL FEATURES', level=1)
ah('Symptoms', level=2, color=(0x2E,0x75,0xB6))
at(['Symptom','Benign (Gallstone/Stone)','Malignant (Cancer)'],
[
    ['ONSET','Sudden; episodic (colicky); may have previous episodes','Insidious; progressive; painless'],
    ['JAUNDICE','Fluctuating (stone may move; cholangitis attacks)','PAINLESS, PROGRESSIVE, DEEPENING jaundice — characteristic of malignant obstruction'],
    ['PAIN','RUQ/epigastric colicky pain (biliary colic); radiation to right shoulder; pain with jaundice','Often PAINLESS (Courvoisier\'s sign); or vague deep epigastric pain radiating to back (head of pancreas tumour involving coeliac plexus = ominous sign)'],
    ['PRURITUS','Present; may precede jaundice','Intense; early; severe — from bile salt accumulation in skin'],
    ['URINE','Dark (bilirubinuria — "Coca-Cola")','Dark; progressive'],
    ['STOOLS','Pale/clay-coloured (acholuric)','Pale; steatorrhoea'],
    ['WEIGHT LOSS','Mild; if cholangitis present','SIGNIFICANT weight loss + anorexia; often >10% body weight — suggests malignancy'],
    ['FEVER / RIGORS','Present with cholangitis (Charcot\'s triad)','Usually absent (unless hepatic duct obstruction with secondary cholangitis)'],
    ['NAUSEA / VOMITING','Present in acute cholangitis','GOO from pancreatic head tumour compressing duodenum (late)'],
])
doc.add_paragraph()

ah('Signs', level=2, color=(0x2E,0x75,0xB6))
at(['Sign','Details'],
[
    ['JAUNDICE (ICTERUS)','Yellow sclera (earliest); yellow skin; yellow mucous membranes. Severity correlates with serum bilirubin — bilirubin >100 μmol/L = deep jaundice'],
    ['SCRATCH MARKS (EXCORIATIONS)','From pruritus; widespread; arms, legs, torso'],
    ["COURVOISIER'S SIGN (LAW)","Palpable, non-tender, distended gallbladder in the presence of jaundice = MALIGNANT cause until proven otherwise. Explanation: In gallstone disease the gallbladder wall is FIBROSED and SCARRED (from chronic cholecystitis) → CANNOT DISTEND even when CBD obstructs. In CANCER: gallbladder is normal (no prior inflammation) → DISTENDS when CBD blocks below cystic duct insertion. EXCEPTION: empyema or mucocele of GB may give palpable tender GB in benign disease."],
    ['HEPATOMEGALY','Tender hepatomegaly (early); firm irregular (chronic/malignant — liver metastases)'],
    ['SPLENOMEGALY','Secondary biliary cirrhosis → portal hypertension (late; chronic obstruction)'],
    ['VIRCHOW\'S NODE (Troisier\'s sign)','Left supraclavicular lymphadenopathy → pancreatic / gastric / biliary malignancy'],
    ['SISTER MARY JOSEPH\'S NODULE','Periumbilical nodule from transcoelemic spread of pancreatic/GI malignancy'],
    ["CHARCOT'S TRIAD (ascending cholangitis)","RUQ pain + Fever/Rigors + JAUNDICE — classic triad of ascending bacterial cholangitis (1877)"],
    ["REYNOLD'S PENTAD (severe cholangitis / suppurative cholangitis)","Charcot's triad + HYPOTENSION + MENTAL CONFUSION (altered consciousness) = severe life-threatening cholangitis; requires URGENT ERCP + biliary drainage + IV antibiotics. Mortality >50% if untreated."],
    ['XANTHELASMA / XANTHOMAS','Cholesterol deposits around eyes + tendons; chronic cholestasis → hypercholesterolaemia'],
    ['MALNUTRITION / WASTING','Malignancy + fat malabsorption'],
    ['PERIPHERAL OEDEMA','Hypoalbuminaemia (hepatic dysfunction in chronic/severe obstruction)'],
])
doc.add_paragraph()

# ─── SECTION 7: INVESTIGATIONS ───
ah('7. INVESTIGATIONS', level=1)
ap('Strategy: CONFIRM obstructive jaundice (LFTs) → LOCALISE obstruction (USS → MRCP/CT → ERCP/EUS) → DETERMINE CAUSE (benign vs malignant) → ASSESS RESECTABILITY (CT staging) + CORRECT COAGULOPATHY before intervention.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Blood Tests', level=2, color=(0x2E,0x75,0xB6))
at(['Test','Finding in Obstructive Jaundice'],
[
    ['SERUM BILIRUBIN (total + direct/indirect)','Total ↑ (>34 μmol/L for clinical jaundice); CONJUGATED (DIRECT) fraction >50% of total = obstructive. Indirect (unconjugated) = pre-hepatic.'],
    ['ALKALINE PHOSPHATASE (ALP)','MARKEDLY ELEVATED — most sensitive test for biliary obstruction; ALP rises before bilirubin and is disproportionately elevated vs transaminases'],
    ['GAMMA-GLUTAMYL TRANSPEPTIDASE (GGT)','↑ Elevated; confirms hepatic origin of raised ALP (rules out bone disease); elevated in alcohol + cholestasis'],
    ['ALT / AST (transaminases)','Mildly elevated (secondary hepatocyte damage from back-pressure); dramatically elevated in acute biliary obstruction or cholangitis (sepsis-induced hepatocellular damage)'],
    ['SERUM ALBUMIN','Reduced in prolonged/chronic obstruction (hepatic synthetic failure); malnutrition in malignancy'],
    ['PROTHROMBIN TIME / INR','PROLONGED — Vitamin K malabsorption → reduced factors II, VII, IX, X; MUST correct with Vitamin K (10 mg IV daily × 3 days) before any intervention'],
    ['SERUM BILIRUBIN trend','Rising bilirubin = progressive obstruction / malignancy; fluctuating = stone disease or hilar stricture'],
    ['FBC','Leucocytosis + neutrophilia in ascending cholangitis; anaemia (malignancy, chronic disease)'],
    ['UREA + CREATININE','Pre-renal uraemia; hepatorenal syndrome risk in severe obstruction; baseline before contrast studies'],
    ['TUMOUR MARKERS','CA 19-9: elevated in pancreatic cancer + cholangiocarcinoma; NOT specific (elevated in benign biliary obstruction too — must interpret in CONTEXT of imaging). CEA: gastric/colonic malignancy causing biliary obstruction. AFP: hepatocellular carcinoma with biliary invasion.'],
    ['URINE EXAMINATION','Bilirubin PRESENT (bilirubinuria = "positive" urine dipstick for bilirubin) — confirms conjugated hyperbilirubinaemia. Urobilinogen ABSENT (no bile reaching intestine).'],
    ['BLOOD CULTURES','Mandatory if fever/rigors (ascending cholangitis) — E. coli, Klebsiella, Enterococcus, Pseudomonas most common organisms'],
])
doc.add_paragraph()

ah('Imaging', level=2, color=(0x2E,0x75,0xB6))
at(['Investigation','Role / Findings'],
[
    ['ULTRASOUND ABDOMEN (USS) — FIRST LINE','BEST initial investigation: detects biliary dilatation (CBD >6 mm, intrahepatic ducts dilated); gallstones (90% sensitivity); gallbladder wall thickening; liver echogenicity; pancreatic mass; liver metastases. LIMITATION: CBD visualisation often poor at lower end (duodenum gas). ALWAYS order USS first.'],
    ['MRCP (Magnetic Resonance Cholangiopancreatography) — NON-INVASIVE BILIARY IMAGING','BEST non-invasive investigation for biliary tree anatomy; highly sensitive (>95%) for CBD stones, strictures, cholangiocarcinoma, pancreatic duct dilatation. Shows LEVEL and CAUSE of obstruction without radiation or contrast injection. PERFORM before ERCP when diagnosis uncertain. MRCP preferred over ERCP for diagnostic purposes only.'],
    ['CT ABDOMEN + CHEST (contrast — portal venous phase) — STAGING','Best for: pancreatic + hepatic mass characterisation; liver metastases (hypodense on portal phase); vascular involvement (SMA/SMV/portal vein — determines resectability); local lymph nodes; distant metastases; peritoneal disease. CT ANGIOGRAPHY: assesses SMA/SMV involvement before Whipple.'],
    ['ERCP (Endoscopic Retrograde Cholangiopancreatography) — THERAPEUTIC','INDICATION: When THERAPEUTIC drainage is required + diagnosis suspected (CBD stones; benign stricture; malignant stricture if stenting needed). NOT first choice for diagnosis alone (MRCP preferred). PROVIDES: sphincterotomy + stone extraction; biliary stent placement (plastic or SEMS); brush cytology / biopsies; pancreatic duct cannulation. COMPLICATION: Post-ERCP pancreatitis (3-5%); bleeding (after sphincterotomy); perforation; cholangitis. RECTAL INDOMETHACIN before ERCP reduces pancreatitis risk 50%.'],
    ['EUS (Endoscopic Ultrasound) — BEST for pancreatic mass staging + biopsy','BEST modality for: T-staging pancreatic head carcinoma; ampullary tumours (depth of invasion); EUS-FNA biopsy (histological diagnosis before surgery/oncological treatment); CBD microlithiasis detection when MRCP equivocal. EUS-guided biliary drainage if ERCP fails (EUS-BD).'],
    ['PTC (Percutaneous Transhepatic Cholangiography) — when ERCP fails','Percutaneous approach through liver parenchyma under US/fluoroscopic guidance; used when: ERCP not possible (previous Roux-en-Y; duodenal obstruction; failed ERCP cannulation); achieves drainage of intrahepatic ducts (superior for hilar strictures). Complications: haemobilia; bile leak; cholangitis; pneumothorax.'],
    ['HEPATOBILIARY SCINTIGRAPHY (HIDA scan)','Technetium-99m-labelled iminodiacetic acid; assesses biliary function + drainage kinetics; used to: confirm biliary obstruction; post-operative bile leak assessment; cystic duct patency'],
    ['INTRADUCTAL ULTRASOUND (IDUS)','Passed through ERCP scope into bile duct; high-resolution images of duct wall; differentiates malignant vs benign stricture; especially useful for hilar lesions and indeterminate strictures'],
    ['LIVER BIOPSY','Percutaneous biopsy CONTRAINDICATED with severe coagulopathy (risk of bile peritonitis + haemobilia). Transjugular route preferred. Used when hepatocellular/parenchymal jaundice suspected.'],
])
doc.add_paragraph()

# ─── SECTION 8: MANAGEMENT ───
ah('8. MANAGEMENT', level=1)
ap('Structured as: Pre-operative preparation → Endoscopic drainage → Interventional radiology → Surgical management (by cause).', bold=True, color=(0x1F,0x4E,0x79))
doc.add_paragraph()

ah('A. PRE-OPERATIVE PREPARATION (Before ANY intervention)', level=2, color=(0x2E,0x75,0xB6))
at(['Step','Action'],
[
    ['VITAMIN K','IV Vitamin K 10 mg daily × 3 days (reverses coagulopathy from malabsorption); PT/INR should normalise within 48-72 hours. If INR does not correct → hepatocellular dysfunction (cannot synthesise factors despite Vit K) → FFP if urgent procedure.'],
    ['FLUID RESUSCITATION + URINE OUTPUT','Adequate IV fluids; catheterise; hourly urine output (target >0.5 mL/kg/hour); prevent hepatorenal syndrome; avoid nephrotoxic drugs (NSAIDs, aminoglycosides, contrast agents)'],
    ['ANTIBIOTICS','Prophylactic broad-spectrum antibiotics before ANY biliary intervention/surgery (e.g., piperacillin-tazobactam or cefuroxime + metronidazole); therapeutic for ascending cholangitis (see below)'],
    ['NUTRITIONAL OPTIMISATION','Pre-operative enteral nutrition if malnourished (esp. malignancy); 1-2 weeks if major hepato-pancreatic surgery planned; low-fat diet to reduce biliary symptoms'],
    ['BILIARY DRAINAGE before surgery','For serum bilirubin >200 μmol/L (>12 mg/dL) before major pancreatic/hepatic resection: ERCP + biliary stenting (reduces post-operative hepatic failure, renal failure, coagulopathy, wound infection). Allows liver recovery before elective surgery. Controversy: pre-operative drainage may increase infective complications (stent infections); used selectively.'],
    ['BLOOD GROUP + CROSS-MATCH','Major hepato-pancreatic surgery carries high blood transfusion risk (especially Whipple\'s, hepatectomy)'],
])
doc.add_paragraph()

ah('B. ASCENDING CHOLANGITIS — EMERGENCY MANAGEMENT', level=2, color=(0x2E,0x75,0xB6))
ap('Charcot\'s triad = RUQ pain + fever/rigors + jaundice. Reynold\'s pentad = adds hypotension + confusion (SEVERE / suppurative cholangitis = SURGICAL EMERGENCY).', bold=True, color=(0xC0,0x00,0x00))
at(['Priority','Action'],
[
    ['IMMEDIATE RESUSCITATION','IV access × 2; aggressive IV fluid resuscitation; blood cultures × 2 before antibiotics; urinary catheter; ICU if Reynold\'s pentad; supplemental O2'],
    ['ANTIBIOTICS (IV IMMEDIATELY)','Piperacillin-tazobactam (Tazocin) 4.5 g IV TDS — FIRST CHOICE (gram-negative + anaerobic cover); or Ceftriaxone 2g IV OD + Metronidazole 500 mg IV TDS; if penicillin allergic: Meropenem 1g IV TDS. Start within 1 hour.'],
    ['URGENT BILIARY DRAINAGE (ERCP) — within 24-48 hours','URGENT ERCP + sphincterotomy + stone extraction + biliary stent placement (if stone cannot be fully cleared); ACHIEVES BILIARY DECOMPRESSION — most important step. If ERCP fails: PTC. If PTC fails or patient too unstable: surgical common bile duct exploration (open choledochotomy — rarely needed now).'],
    ['DEFINITIVE MANAGEMENT (after recovery)','Laparoscopic cholecystectomy on same admission (if stable) or within 6 weeks — prevents recurrence of cholangitis (recurrence 15-25% without cholecystectomy)'],
])
doc.add_paragraph()

ah('C. CHOLEDOCHOLITHIASIS (CBD STONES) — MANAGEMENT', level=2, color=(0x2E,0x75,0xB6))
at(['Scenario','Management'],
[
    ['Suspected CBD stone + jaundice (pre-operative — planned cholecystectomy)','MRCP (if bilirubin mildly elevated) to confirm CBD stone → ERCP + sphincterotomy + stone extraction → laparoscopic cholecystectomy within 72 hours (same admission or 2-4 weeks)'],
    ['CBD stone confirmed on USS / MRCP','ERCP + sphincterotomy (endoscopic stone extraction): Mechanical lithotripsy (for large stones); Electrohydraulic lithotripsy (EHL) or Laser lithotripsy (for very large stones); Balloon sweep + basket extraction'],
    ['Laparoscopic intraoperative cholangiogram shows CBD stone','LAPAROSCOPIC CBD EXPLORATION (LCBDE) — transcystic duct or choledochotomy approach; T-tube placement after open choledochotomy (T-tube cholangiogram at Day 10 before removal); OR convert to ERCP post-operatively'],
    ['Elderly / high surgical risk + CBD stone','ERCP + sphincterotomy alone (without cholecystectomy) — reduces cholecystitis recurrence; acceptable in very high risk patients (observational management of gallbladder)'],
    ['LARGE / IMPACTED CBD STONES not clearable by ERCP','Endoscopic papillary large balloon dilation (EPLBD); SpyGlass direct cholangioscopy + lithotripsy; Surgical choledochotomy + T-tube drainage'],
])
doc.add_paragraph()

ah('D. SURGICAL MANAGEMENT OF MALIGNANT OBSTRUCTIVE JAUNDICE', level=2, color=(0x2E,0x75,0xB6))
ap('ASSESS RESECTABILITY FIRST (CT staging + EUS + MDT discussion) before offering surgical resection.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()
ap('WHIPPLE\'S PANCREATICODUODENECTOMY (Pancreaticoduodenectomy):', bold=True, color=(0x1F,0x4E,0x79))
at(['Aspect','Detail'],
[
    ['INDICATION','Resectable carcinoma of: pancreatic HEAD; ampulla of Vater (best prognosis); distal CBD cholangiocarcinoma; duodenal carcinoma (D1-D2); benign: chronic pancreatitis head with intractable pain + ductal obstruction; pancreatic cystadenoma in head'],
    ['STANDARD RESECTION (Classic Whipple)','Removes: pancreatic head + neck + uncinate process + duodenum (D1-D4) + distal stomach (30%) + distal CBD + gallbladder + regional lymph nodes. Vascular: SMA + SMV + portal vein — MUST preserve (if >180° encasement = unresectable in most centres)'],
    ['PYLORUS-PRESERVING PANCREATICODUODENECTOMY (PPPD — Traverso-Longmire)','Preserves entire stomach + pylorus + first 2 cm of duodenum; same oncological outcome; reduces delayed gastric emptying (debated); preferred by most modern centres for periampullary cancers'],
    ['RECONSTRUCTION (3 anastomoses)','(1) PANCREATICOJEJUNOSTOMY / PANCREATICOGASTROSTOMY (most technically demanding — highest risk of pancreatic fistula); (2) HEPATICOJEJUNOSTOMY (bile duct to jejunum); (3) GASTROJEJUNOSTOMY or DUODENOJEJUNOSTOMY — all on a Roux-en-Y limb'],
    ['CRITERIA FOR UNRESECTABILITY','Distant metastases (liver, peritoneal, lung); Encasement of SMA >180°; Encasement of coeliac axis; Aortic invasion; Bilateral portal vein or SMV involvement (relative contraindication); Lymph node involvement beyond regional field'],
    ['MORBIDITY / MORTALITY','Operative mortality now <3-5% at specialist HPB centres; Morbidity 40-50%. Main complications: Pancreatic fistula (most common — 10-25%); Delayed gastric emptying (10-25%); Post-pancreatectomy haemorrhage; Bile leak; Wound infection'],
    ['5-YEAR SURVIVAL','Pancreatic cancer: 15-20% (R0 resection); Ampullary carcinoma: 50-60% (best); Distal CBD cholangiocarcinoma: 25-40%; Duodenal carcinoma: 40-50%'],
])
doc.add_paragraph()

ap('OTHER SURGICAL PROCEDURES FOR MALIGNANT OBSTRUCTIVE JAUNDICE:', bold=True, color=(0x1F,0x4E,0x79))
at(['Procedure','Indication / Details'],
[
    ['HEPATECTOMY (right/left/extended) + Bile duct resection','Hilar cholangiocarcinoma (Klatskin tumour; Bismuth IIIa → right hepatectomy; IIIb → left hepatectomy); combined with caudate lobectomy (segment I always involved in hilar CCA) + biliary reconstruction'],
    ['DISTAL PANCREATECTOMY + SPLENECTOMY','Pancreatic body/tail carcinoma causing biliary obstruction (rare — usually obstructs main PD not CBD); insulinoma/glucagonoma of body/tail'],
    ['LIVER TRANSPLANTATION for hilar CCA','Very selected Type IV Bismuth hilar CCA in specialist centres (Mayo Clinic protocol: neoadjuvant CRT → transplant; 5yr survival 65-80% for selected patients)'],
    ['PALLIATIVE BILIARY BYPASS (hepaticojejunostomy or choledochojejunostomy)','If resection not possible intraoperatively (unexpected unresectable disease found at laparotomy); provides durable biliary drainage for 12-24 months; better than stenting if expected survival >6 months'],
    ['PALLIATIVE GASTROJEJUNOSTOMY','For pancreatic head cancer causing/threatening GOO; combined with hepaticojejunostomy at same procedure (double bypass = hepaticojejunostomy + gastrojejunostomy for unresectable pancreatic cancer)'],
    ['CHOLECYSTOJEJUNOSTOMY','Palliative bypass of distal CBD obstruction via gallbladder; ONLY if cystic duct patent (insert catheter into GB → into CBD to confirm); technically simpler than hepaticojejunostomy; slightly less reliable'],
])
doc.add_paragraph()

ah('E. ENDOSCOPIC / RADIOLOGICAL PALLIATION (Non-surgical)', level=2, color=(0x2E,0x75,0xB6))
at(['Intervention','Detail'],
[
    ['ENDOSCOPIC BILIARY STENTING (ERCP)','PLASTIC STENT (10 Fr): short-term; 3-4 months patency; replaceable; preferred for benign strictures + preoperative drainage. SELF-EXPANDING METAL STENT (SEMS): covered or uncovered; 6-12 months patency; for malignant obstruction; preferred for palliative intent (no surgery planned). UNCOVERED SEMS: for distal malignant strictures; cannot be removed. COVERED SEMS: for benign strictures; retrievable.'],
    ['PTC + EXTERNAL BILIARY DRAINAGE','When ERCP not possible (hilar obstruction; prior Roux-en-Y; failed ERCP); percutaneous right-sided or left-sided approach; external drainage bag initially; convert to internal stent or internal-external drain'],
    ['EUS-GUIDED BILIARY DRAINAGE (EUS-BD)','Emerging technique when ERCP fails; EUS-guided puncture of dilated intrahepatic duct or gallbladder → rendezvous procedure with ERCP; or direct transluminal stent placement (hepaticogastrostomy or choledochoduodenostomy)'],
])
doc.add_paragraph()

ah('F. MIRIZZI SYNDROME (Special Topic in Biliary Surgery)', level=2, color=(0x2E,0x75,0xB6))
at(['Type','Description','Management'],
[
    ['Type I (McSherry)','Stone impacted in cystic duct or Hartmann\'s pouch externally compresses CHD (no fistula)','Laparoscopic or open cholecystectomy + Calot\'s triangle dissection (careful — risk of CHD injury); subtotal cholecystectomy if dense adhesions'],
    ['Type II','Stone erodes partially through cystic-hepatic duct junction (fistula <1/3 circumference)','Partial cholecystectomy + primary repair + T-tube drainage; or biliary-enteric anastomosis'],
    ['Type III','Fistula involves >1/3 but <2/3 circumference','Biliary-enteric bypass (hepaticojejunostomy) usually required'],
    ['Type IV','Complete erosion into CHD — common duct exposed (2/3 to complete)','Hepaticojejunostomy Roux-en-Y'],
    ['Mirizzi Type V (Csendes — newer)','Stone erodes into duodenum/colon (bilioenteric fistula); Bouveret\'s syndrome if stone in duodenum → GOO','Surgical repair of fistula + cholecystectomy; Bouveret\'s → remove stone via duodenum + cholecystectomy'],
])
doc.add_paragraph()

# ─── SECTION 9: COMPLICATIONS ───
ah('9. COMPLICATIONS OF OBSTRUCTIVE JAUNDICE (PRE-OPERATIVE)', level=1)
at(['Complication','Details + Prevention'],
[
    ['ASCENDING CHOLANGITIS','Biliary stasis + infection → septicaemia; E. coli, Klebsiella, Enterococcus; Charcot\'s triad / Reynold\'s pentad; urgent ERCP + antibiotics'],
    ['COAGULOPATHY','Vitamin K malabsorption → prolonged PT/INR; administer IV Vit K 3 days pre-op'],
    ['HEPATORENAL SYNDROME (HRS)','Conjugated bilirubin + endotoxaemia → renal tubular injury; maintain urine output >0.5 mL/kg/hr; avoid nephrotoxins; pre-op biliary drainage'],
    ['NUTRITIONAL DEFICIENCY + MALNUTRITION','Fat-soluble vitamin deficiency (K, A, D, E); steatorrhoea; pre-operative enteral nutrition'],
    ['SECONDARY BILIARY CIRRHOSIS','Chronic obstruction (months-years) → fibrosis → portal hypertension; early diagnosis + drainage prevents this'],
    ['HAEMOBILIA','Blood in bile duct → haemobilia; from arterio-biliary fistula (trauma, PTC, post-biopsy, aneurysm); presents with Quincke\'s triad: biliary colic + jaundice + GI bleeding; treat with angioembolisation'],
])
doc.add_paragraph()

# ─── SECTION 10: RECENT ADVANCES ───
ah('10. RECENT ADVANCES', level=1)
advances=[
    'EUS-GUIDED BILIARY DRAINAGE (EUS-BD): When ERCP fails — EUS-guided hepaticogastrostomy or choledochoduodenostomy; success rate >90%; avoids percutaneous approach; now performed in advanced endoscopy centres. For both benign + malignant obstruction.',
    'FULLY COVERED SELF-EXPANDING METAL STENTS (FCSEMS) for benign biliary strictures: Retrievable; 12-month patency superior to plastic stents; used for post-cholecystectomy strictures, PSC, chronic pancreatitis strictures.',
    'DIGITAL CHOLANGIOSCOPY (SpyGlass DS2): Single-operator direct visualisation inside bile duct; targeted biopsies of indeterminate strictures (sensitivity >80%); electrohydraulic / laser lithotripsy for difficult CBD stones.',
    'LAPAROSCOPIC / ROBOTIC WHIPPLE\'S PANCREATICODUODENECTOMY: Laparoscopic PD gaining adoption at high-volume HPB centres; similar oncological outcomes to open; reduced wound complications; longer operative time. Robot-assisted PD improves ergonomics for complex anastomoses.',
    'NEOADJUVANT CHEMOTHERAPY FOR BORDERLINE RESECTABLE PANCREATIC CANCER: FOLFIRINOX (5-FU + Leucovorin + Irinotecan + Oxaliplatin) or Gemcitabine + nab-Paclitaxel (MPACT trial) as neoadjuvant therapy in borderline resectable disease to downsize tumour + sterilise margins before Whipple\'s. Improves R0 resection rate + median OS.',
    'TOTAL NEOADJUVANT THERAPY (TNT) for LAPC (locally advanced pancreatic cancer): All chemotherapy given upfront; conversion surgery in 15-20% previously unresectable patients.',
    'IMMUNOTHERAPY for dMMR/MSI-H pancreatic cancer: Pembrolizumab (KEYNOTE-158); rare but actionable mutation; ~1% of pancreatic cancers.',
    'MRCP 3T MRI: High-resolution MRCP on 3-Tesla MRI provides near-ERCP-quality duct imaging non-invasively; changing practice for pre-operative biliary mapping.',
    'PREOPERATIVE BILIARY DRAINAGE CONTROVERSY: PREP RCT (NEJM 2010): Pre-operative biliary drainage before Whipple\'s for jaundice did NOT improve outcomes and increased infective complications — routine pre-operative drainage now NOT recommended for bilirubin <200 μmol/L; only for severe jaundice or delayed surgery.',
    'PORTAL BILIOPATHY in India: Symptomatic biliary obstruction from enlarged periportal collaterals in EHPVO (extrahepatic portal vein obstruction); unique to India/Asia; managed by Rex shunt (mesentericoportal bypass) or ERCP + biliary drainage.',
]
for a in advances: ab(a)
doc.add_paragraph()

# ─── SECTION 11: SCORING GUIDE ───
ah("11. EXAMINER'S SCORING GUIDE — 30 Marks", level=1)
at(['Section','Marks'],
[
    ['Surgical anatomy: Biliary tree (extrahepatic ducts, CBD, ampulla, Calot\'s triangle, Couinaud segments, CBD blood supply)','5'],
    ['Definition + full classification of jaundice (pre-hepatic / hepatic / obstructive — table with urine + stool + bilirubin)','3'],
    ['Causes of obstructive jaundice (benign vs malignant; periampullary tumours; Bismuth classification for hilar CCA)','3'],
    ['Pathophysiology (bile obstruction → conjugated bilirubinaemia → Vit K malabsorption → coagulopathy → pruritus → cholangitis → HRS)','3'],
    ['Clinical features (Charcot\'s triad; Reynold\'s pentad; Courvoisier\'s sign; dark urine + pale stools; pruritus)','3'],
    ['Investigations (LFTs; USS; MRCP; CT; ERCP; EUS; PTC; CA 19-9)','3'],
    ['Management: preoperative preparation (Vit K + fluids + antibiotics + nutrition) + ascending cholangitis emergency','3'],
    ['Surgical management: Whipple\'s PD (PPPD + 3 anastomoses + resectability criteria + complications) + other surgical options (hepatectomy, biliary bypass, Mirizzi)','5'],
    ['Recent advances (EUS-BD, SpyGlass, robotic Whipple, neoadjuvant FOLFIRINOX, pre-op drainage controversy)','2'],
    ['TOTAL','30'],
])
doc.add_paragraph()

ah('Sharp-Edge Discriminators — Mark-Winners', level=2, color=(0x2E,0x75,0xB6))
tips=[
    'CBD diameter: Normal <6 mm; >6 mm = dilated = obstruction (>8 mm after cholecystectomy acceptable). Intrahepatic ducts dilated = confirms obstruction is at or above CHD.',
    'ALP = most sensitive early marker of biliary obstruction (rises before bilirubin becomes visible).',
    'Conjugated bilirubin = water-soluble = excreted in urine = DARK URINE. Unconjugated = not water-soluble = NOT in urine.',
    'Urobilinogen ABSENT in urine = obstructive jaundice (no bile reaching intestine). Urobilinogen ELEVATED = pre-hepatic haemolytic.',
    'Courvoisier\'s law: Palpable non-tender gallbladder + jaundice = MALIGNANT obstruction (NOT gallstone — fibrosed GB cannot distend).',
    'Charcot\'s triad = Pain + Fever + Jaundice. Reynold\'s pentad = Charcot\'s + Hypotension + Mental confusion = suppurative cholangitis = EMERGENCY.',
    'Calot\'s triangle: Visceral surface liver (roof) + CHD (medial) + Cystic duct (floor). Contents: cystic artery, node of Calot, right hepatic artery. Source: Fischer\'s Mastery p. 4554.',
    'Cystic artery = branch of RIGHT HEPATIC ARTERY (usually); but can arise from any nearby vessel — always verify in Calot\'s.',
    'Bismuth Type IV hilar cholangiocarcinoma = involves both hepatic ducts = often unresectable; Bismuth IIIa → right hepatectomy; IIIb → left hepatectomy; ALWAYS with caudate lobectomy (segment I drains into both sides).',
    'MRCP = non-invasive FIRST choice for biliary imaging (after USS). ERCP = therapeutic (NOT diagnostic first choice anymore).',
    'Whipple\'s PD removes: pancreatic head + neck + uncinate + duodenum + distal CBD + gallbladder + regional LN; standard Whipple includes distal gastrectomy 30%.',
    'PPPD (Traverso-Longmire) = preserves pylorus + 2 cm D1; same oncological outcomes as classic Whipple; preferred at most modern centres.',
    'THREE anastomoses in Whipple reconstruction: Pancreaticojejunostomy (highest risk) + Hepaticojejunostomy + Gastro/duodenojejunostomy (all Roux-en-Y).',
    'Post-Whipple complications: Pancreatic fistula (10-25%) = MOST COMMON; Delayed gastric emptying (10-25%); Post-pancreatectomy haemorrhage.',
    'Ampullary carcinoma = BEST prognosis of periampullary tumours (50-60% 5-yr survival after Whipple\'s); pancreatic cancer = WORST (15-20%).',
    'Pre-operative biliary drainage: NOT routinely recommended before Whipple\'s for bilirubin <200 μmol/L (PREP RCT, NEJM 2010 — increased infective complications with routine drainage).',
    'FOLFIRINOX neoadjuvant for borderline resectable pancreatic cancer — improves R0 resection rate + median OS.',
    'Mirizzi syndrome = stone in Hartmann\'s pouch/cystic duct compressing CHD; treat by careful Calot\'s dissection; subtotal cholecystectomy if dense adhesions; hepaticojejunostomy if Type III-IV fistula.',
    'Vitamin K deficiency in obstructive jaundice: Give IV Vit K 10 mg OD × 3 days before surgery; PT should normalise. If PT does not correct = hepatocellular dysfunction (need FFP).',
    'Portal biliopathy (India) = biliary obstruction from EHPVO periportal collaterals; treat with Rex shunt or ERCP drainage.',
]
for t in tips: ab(t)
doc.add_paragraph()
ps=doc.add_paragraph()
rs=ps.add_run("Sources: Bailey & Love's Short Practice of Surgery 28th Ed. (Ch. 69-70) | Fischer's Mastery of Surgery 8th Ed. (Ch. 165, p. 4550-4555) | Sabiston Textbook of Surgery 21st Ed. | Yamada's Textbook of Gastroenterology 7th Ed. | Current Surgical Therapy 14e | Schwartz's Principles of Surgery 11th Ed.")
rs.italic=True; rs.font.size=Pt(9); rs.font.color.rgb=RGBColor(0x70,0x70,0x70)

out='/tmp/workspace/ms-surgery-notes/Obstructive_Jaundice_30marks.docx'
doc.save(out)
print(f'Saved: {out}')

from docx import Document
from docx.shared import Pt, RGBColor, Inches, Cm
from docx.enum.text import WD_ALIGN_PARAGRAPH
from docx.oxml.ns import qn
from docx.oxml import OxmlElement
import requests

doc = Document()
sec = doc.sections[0]
sec.top_margin = Cm(2); sec.bottom_margin = Cm(2)
sec.left_margin = Cm(2.5); sec.right_margin = Cm(2.5)
doc.styles['Normal'].font.name = 'Arial'
doc.styles['Normal'].font.size = Pt(11)
for i in range(1, 4):
    doc.styles[f'Heading {i}'].font.name = 'Arial'

def ah(text, level=1, color=(0x1F,0x4E,0x79)):
    p = doc.add_heading(text, level=level)
    for r in p.runs: r.font.color.rgb = RGBColor(*color)
    return p

def ap(text, bold=False, italic=False, color=None, size=11):
    p = doc.add_paragraph()
    r = p.add_run(text); r.bold=bold; r.italic=italic; r.font.size=Pt(size)
    if color: r.font.color.rgb = RGBColor(*color)
    p.paragraph_format.space_after = Pt(4)
    return p

def ab(text, bold=False):
    p = doc.add_paragraph(style='List Bullet')
    p.paragraph_format.left_indent = Inches(0.3)
    r = p.add_run(text); r.font.size=Pt(11); r.bold=bold
    return p

def scbg(cell, hx):
    tc=cell._tc; tcPr=tc.get_or_add_tcPr()
    shd=OxmlElement('w:shd')
    shd.set(qn('w:val'),'clear'); shd.set(qn('w:color'),'auto')
    shd.set(qn('w:fill'),hx); tcPr.append(shd)

def at(headers, rows, hc='1F4E79', arc='D6E4F0'):
    tbl=doc.add_table(rows=1+len(rows), cols=len(headers))
    tbl.style='Table Grid'
    hr=tbl.rows[0].cells
    for i,h in enumerate(headers):
        hr[i].text=h; scbg(hr[i],hc)
        for p in hr[i].paragraphs:
            for r in p.runs:
                r.bold=True; r.font.size=Pt(10); r.font.color.rgb=RGBColor(0xFF,0xFF,0xFF)
    for ri,rd in enumerate(rows):
        cs=tbl.rows[ri+1].cells
        for ci,txt in enumerate(rd):
            cs[ci].text=txt
            for p in cs[ci].paragraphs:
                for r in p.runs: r.font.size=Pt(10)
        if ri%2==0:
            for c in cs: scbg(c,arc)
    return tbl

def embed_img(url, path, w=Inches(5.5), cap=None):
    try:
        r=requests.get(url,timeout=15)
        if r.status_code==200:
            with open(path,'wb') as f: f.write(r.content)
            doc.add_picture(path,width=w)
            doc.paragraphs[-1].alignment=WD_ALIGN_PARAGRAPH.CENTER
            if cap:
                c=doc.add_paragraph(cap); c.alignment=WD_ALIGN_PARAGRAPH.CENTER
                c.runs[0].italic=True; c.runs[0].font.size=Pt(9)
    except:
        ap(f'[Image: {cap}]',italic=True,color=(0x70,0x70,0x70))

# ─── COVER ───
p=doc.add_paragraph(); p.alignment=WD_ALIGN_PARAGRAPH.CENTER
r=p.add_run('MS GENERAL SURGERY — EXAM NOTES')
r.bold=True; r.font.size=Pt(18); r.font.color.rgb=RGBColor(0x1F,0x4E,0x79)
p2=doc.add_paragraph(); p2.alignment=WD_ALIGN_PARAGRAPH.CENTER
r2=p2.add_run('Intestinal Obstruction — 30-Mark Question')
r2.bold=True; r2.font.size=Pt(14); r2.font.color.rgb=RGBColor(0x2E,0x75,0xB6)
p3=doc.add_paragraph(); p3.alignment=WD_ALIGN_PARAGRAPH.CENTER
r3=p3.add_run("Sources: Bailey & Love 28th Ed. | Fischer's Mastery 8th Ed. | Sabiston 21st Ed. | Current Surgical Therapy 14e | Grainger & Allison Radiology | Schwartz's 11th Ed.")
r3.italic=True; r3.font.size=Pt(10); r3.font.color.rgb=RGBColor(0x70,0x70,0x70)
doc.add_paragraph()
pq=doc.add_paragraph()
pq.add_run('EXAM QUESTION: "Classify intestinal obstruction. Describe its causes, pathophysiology, clinical features, investigations and management including surgical options. Add a note on volvulus, intussusception and pseudo-obstruction."   [30 Marks]').bold=True
pq.runs[0].font.size=Pt(11); pq.runs[0].font.color.rgb=RGBColor(0x7B,0x22,0x00)
doc.add_paragraph()

embed_img(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_0a1d7b7dcccf02bb869fc5244717486e3e87ea096c97cecdafb5e750af244b1c.jpg',
    '/tmp/workspace/ms-surgery-notes/sbo_xray_ct.jpg', w=Inches(5.2),
    cap='Figure 1: Small bowel obstruction (SBO). (a) Erect AXR: multiple dilated small bowel loops with prominent air-fluid levels — hallmark of mechanical SBO. (b-d) CT abdomen: dilated small bowel loops with transition zone (arrow), wall thickening and clustering — confirms mechanical obstruction with strangulation risk. Source: PMC/Radiology'
)
embed_img(
    'https://cdn.orris.care/cdss_images/pmc_clinical_VQA_d68d6a17415e1eab4656d2818313fdcc9310173cb8ecc279a9d59a2df759c51f.jpg',
    '/tmp/workspace/ms-surgery-notes/sigmoid_volvulus_xray.jpg', w=Inches(5.2),
    cap="Figure 2: Sigmoid volvulus — Classic 'coffee bean' sign / inverted U-loop. Massively dilated, haustrum-free sigmoid colon occupying most of the abdominal cavity. The two limbs meet at the pelvis forming the 'bean crease'. Absence of rectal gas = complete obstruction. Urgent endoscopic decompression required. Source: PMC/Radiology"
)
doc.add_paragraph()

# ─── SECTION 1: DEFINITION ───
ah('1. DEFINITION', level=1)
ap('INTESTINAL OBSTRUCTION = mechanical or functional hindrance to the normal propulsion of intestinal contents through the alimentary canal, proximal to which there is dilatation and distal to which there is collapse.', bold=True)
ab('Most common surgical emergency involving the abdomen worldwide')
ab('SMALL BOWEL OBSTRUCTION (SBO) = 60-70% of all mechanical intestinal obstruction; LARGE BOWEL OBSTRUCTION (LBO) = 25-30%')
ab('Mortality if untreated: Simple SBO = 5%; Strangulation = 20-40% (rises to 60-80% if bowel perforates)')
doc.add_paragraph()

# ─── SECTION 2: CLASSIFICATION ───
ah('2. CLASSIFICATION OF INTESTINAL OBSTRUCTION', level=1)
ap('HIGH-YIELD — examiner EXPECTS a systematic classification table. Use BOTH the functional/mechanical AND the simple/strangulation/closed-loop axes.', bold=True, color=(0xC0,0x00,0x00))
at(['Class','Type','Definition / Key Features'],
[
    ['BY MECHANISM','MECHANICAL OBSTRUCTION','Physical barrier to bowel lumen. Subdivided by: site of blockage (intraluminal / mural / extramural); simple vs strangulated; and anatomical level (SBO vs LBO). Accounts for ~80% of intestinal obstruction.'],
    ['BY MECHANISM','FUNCTIONAL OBSTRUCTION (Paralytic Ileus / Pseudo-obstruction)','No physical obstruction; failure of peristalsis due to neuromuscular or metabolic dysfunction. Bowel dilates throughout (unlike mechanical — no collapsed distal segment). Causes: post-operative ileus; peritonitis; electrolyte disturbance (hypokalaemia); drugs (opioids, anticholinergics); trauma; retroperitoneal haematoma; spinal injury; Ogilvie\'s syndrome.'],
    ['BY BLOOD SUPPLY','SIMPLE (Non-strangulated)','Lumen obstructed but blood supply INTACT. Closed-loop obstruction risk. Mortality low if treated promptly.'],
    ['BY BLOOD SUPPLY','STRANGULATED','Blood supply to the obstructed segment is COMPROMISED → bowel ischaemia → necrosis → perforation → peritonitis. Surgical EMERGENCY. Mortality 20-40%.'],
    ['BY BLOOD SUPPLY','CLOSED-LOOP OBSTRUCTION','BOTH ends of a loop of bowel are obstructed simultaneously (e.g., volvulus; obstructed loop hernia; LBO with competent ileocaecal valve). Rapidly progresses to strangulation. Very high risk of perforation.'],
    ['BY LEVEL','SMALL BOWEL (SBO)','High (jejunal) or Low (ileal). More common (60-70%). Causes differ from LBO.'],
    ['BY LEVEL','LARGE BOWEL (LBO)','Left or Right colon. Less common (25-30%). Causes differ — carcinoma is commonest.'],
    ['BY ONSET','ACUTE','Sudden onset; complete obstruction.'],
    ['BY ONSET','SUBACUTE / CHRONIC','Partial obstruction; intermittent; insidious. E.g., carcinoma with partial lumen narrowing.'],
    ['BY CAUSE','CONGENITAL','Atresia, malrotation, Hirschsprung\'s, meconium ileus — mainly in neonates/infants.'],
    ['BY CAUSE','ACQUIRED','Most adult cases — adhesions, hernia, tumour, volvulus, diverticular disease.'],
])
doc.add_paragraph()

ah('Anatomical Classification — By Site of Obstruction', level=2, color=(0x2E,0x75,0xB6))
at(['Site of Block','Mechanism','Clinical Impact'],
[
    ['INTRALUMINAL (within the lumen)','Impacted gallstone (gallstone ileus); faecalith; food bolus; large polyp; bezoar; Ascaris lumbricoides (worm bolus — India); foreign body (swallowed); meconium','Often partial obstruction initially; may become complete'],
    ['MURAL (in the bowel wall)','Carcinoma (colon, small bowel — rare); Crohn\'s disease (inflammatory stricture); post-radiation stricture; diverticular stricture; tuberculosis (TB) stricture (India — ileocaecal TB); ischaemic stricture','Progressive obstruction; malignancy most common mural LBO cause'],
    ['EXTRALUMINAL (outside bowel — extrinsic compression)','ADHESIONS (most common overall SBO cause); External hernias (inguinal, femoral, umbilical, incisional — bowel strangulates in narrow neck); Internal hernia (through mesenteric defect, Winslow foramen, post-Roux-en-Y bypass); Volvulus; Intussusception; Pelvic tumour (ovarian cancer, fibroids); Lymph nodes (TB, lymphoma); Abdominal aortic aneurysm pressing on duodenum','Most common cause of mechanical obstruction'],
])
doc.add_paragraph()

# ─── SECTION 3: CAUSES ───
ah('3. CAUSES OF INTESTINAL OBSTRUCTION', level=1)
at(['Cause','Small Bowel (SBO)','Large Bowel (LBO)'],
[
    ['ADHESIONS (post-operative)','MOST COMMON cause of SBO in developed world (60-70%); from previous abdominal surgery — especially gynaecological, colorectal, appendicectomy; fibrous bands kink/compress bowel','Rare cause of LBO'],
    ['HERNIA (external/internal)','SECOND MOST COMMON cause of SBO (15-20%); inguinal > femoral > umbilical > incisional > internal; FEMORAL hernia has highest strangulation rate (40%)','Obturator hernia (Howship-Romberg sign — medial thigh pain); rare'],
    ['MALIGNANCY / TUMOUR','Small bowel tumours (rare — <3%); lymphoma; carcinoid','MOST COMMON cause of LBO in developed world (60-65%); carcinoma sigmoid colon most common site (60% of colorectal cancers causing obstruction)'],
    ['VOLVULUS','Small bowel volvulus (secondary to adhesion or congenital band)','SIGMOID VOLVULUS (most common type — elderly, institutionalised, West Africa = young); CAECAL VOLVULUS (younger, 30-60 yrs); Transverse colon volvulus (rare)'],
    ['INTUSSUSCEPTION','COMMON in children (ileocolic — 77%; 3-12 months peak); idiopathic in children (viral lymphoid hyperplasia); Adults: always a lead point (tumour, polyp, Meckel\'s diverticulum, lymphoma)','Adults: colonic polyp/cancer as lead point'],
    ['CROHN\'S DISEASE','Chronic strictures from transmural inflammation + fibrosis','Less common LBO cause'],
    ['DIVERTICULAR DISEASE','Rare','Second most common LBO cause (15%); diverticular stricture or acute diverticulitis with peridiverticular abscess/fistula'],
    ['GALLSTONE ILEUS','Gallstone >2.5 cm erodes through GB wall into duodenum (cholecystoduodenal fistula) → impacts at terminal ileum (narrowest part)','Bouveret syndrome (stone impacts in duodenum → GOO)'],
    ['RADIATION STRICTURE','Post-radiation for gynaecological/prostate/rectal cancer','Post-radiation proctitis/stricture'],
    ['ILEOCAECAL TB (India)','India: TB strictures (ileocaecal region most common) — hyperplastic form → obstructs ileum; ulcerative form → strictures','Colonic TB stricture; rare'],
    ['HIRSCHSPRUNG\'S DISEASE','Congenital — absent ganglion cells in rectosigmoid → functional obstruction in neonates; can present late as chronic constipation',''],
    ['MECONIUM ILEUS','Neonates with cystic fibrosis; thick meconium obstructs terminal ileum',''],
    ['PSEUDO-OBSTRUCTION (Ogilvie)','Functional — paralytic ileus (post-op, metabolic, drugs, peritonitis)','COLONIC PSEUDO-OBSTRUCTION (Ogilvie\'s syndrome): massive caecal dilatation without mechanical cause; elderly, bed-bound, post-op, cardiac; risk of caecal perforation if >12 cm'],
])
doc.add_paragraph()
ap('INDIA-SPECIFIC causes: Ileocaecal tuberculosis (hyperplastic TB → ileocaecal obstruction; commonest cause of ileocaecal mass obstruction in India); Ascaris worm bolus (ileal obstruction from mass of worms — children); Sigmoid volvulus in young adults (high-residue diet + long sigmoid mesocolon in African/Indian populations).', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

# ─── SECTION 4: PATHOPHYSIOLOGY ───
ah('4. PATHOPHYSIOLOGY', level=1)
at(['Stage','Event','Consequence'],
[
    ['INITIAL OBSTRUCTION','Lumen blocked → bowel proximal to obstruction distends; distal bowel empties (no gas/stool below)','Abdominal distension; absolute constipation to flatus + faeces'],
    ['FLUID + GAS ACCUMULATION','Intestinal secretions (normally 8-9 litres/day reabsorbed) cannot pass obstruction → accumulate proximally; gas from swallowed air + bacterial fermentation','Massive third-space fluid loss → HYPOVOLAEMIA; distension worsens'],
    ['VOMITING','Reverse peristalsis above obstruction → vomiting; HIGH obstruction (proximal jejunum) = early, frequent, bilious vomiting; LOW obstruction (ileum/colon) = late, faeculent vomiting (bacterial overgrowth + fermentation)','DEHYDRATION; ELECTROLYTE IMBALANCE (hypokalaemia, hyponatraemia, metabolic alkalosis from high SBO; metabolic acidosis from strangulation/ischaemia)'],
    ['BACTERIAL OVERGROWTH','Stasis → bacterial proliferation in obstructed gut (normally relatively sterile); gram-negative bacteria predominate; endotoxin production','ENDOTOXAEMIA; bacterial translocation through ischaemic gut wall → SYSTEMIC SEPSIS'],
    ['RAISED INTRALUMINAL PRESSURE','Distension → raised intraluminal pressure → impairs capillary perfusion of gut wall → mucosal ischaemia → breakdown of mucosal barrier','Bacterial translocation; peritonitis risk'],
    ['STRANGULATION','When mesentery becomes kinked or compressed (volvulus, tight hernia neck): VENOUS obstruction first → mucosal oedema → then ARTERIAL occlusion → bowel infarction; Venous infarction = haemorrhagic; Arterial = white/grey infarction','BOWEL GANGRENE → PERFORATION → FAECAL PERITONITIS → SEPTIC SHOCK → DEATH. Mortality 20-40%.'],
    ['CLOSED-LOOP OBSTRUCTION','Both ends of loop blocked (volvulus; LBO with competent IC valve) → no decompression possible; rapid pressure rise → early strangulation','Caecal perforation risk when diameter >12 cm (LBO); Caecum is the highest-risk site (widest lumen, Laplace law: T = P×r)'],
    ['ELECTROLYTE ABNORMALITIES','HIGH SBO (gastric + duodenal): vomiting → loss of HCl → HYPOCHLORAEMIC METABOLIC ALKALOSIS + HYPOKALAEMIA; LOW SBO: vomiting of intestinal fluid → more MIXED picture; STRANGULATION: lactic acidosis → METABOLIC ACIDOSIS','Correct electrolytes before surgery; K+ supplementation essential'],
])
doc.add_paragraph()

# ─── SECTION 5: CLINICAL FEATURES ───
ah('5. CLINICAL FEATURES', level=1)
ap('Cardinal features of mechanical intestinal obstruction (PAIN-VOMIT-DISTENSION-CONSTIPATION): All 4 may not be present simultaneously — pattern depends on LEVEL of obstruction.', bold=True, color=(0x1F,0x4E,0x79))
at(['Feature','SBO (High — Jejunum)','SBO (Low — Ileum)','LBO'],
[
    ['PAIN','Early, severe, colicky (every 3-5 min — jejunum); central abdominal; periumbilical','Every 10-15 min (ileal); central-lower abdominal','Every 15-20 min; lower abdominal / central; onset may be insidious'],
    ['VOMITING','EARLY + PROFUSE (bilious → bile-stained; high volume; reflex)','Later; increasing faeculent quality','LATE (faeculent); may be absent in early LBO'],
    ['DISTENSION','MILD / MINIMAL (stomach + small bowel empty quickly)','MODERATE (central abdomen)','GROSS peripheral/frame distension; caecum + colon dilated'],
    ['CONSTIPATION (to flatus + faeces)','LATE; may still pass flatus + stool initially from distal bowel','Present; absolute constipation late','EARLY; absolute constipation to both flatus + faeces; characteristic of LBO'],
    ['BOWEL SOUNDS','HIGH-PITCHED, TINKLING, HYPERACTIVE (early); absent (late strangulation / peritonitis)','Same','Loud borborygmi (early); diminished/absent late'],
    ['DEHYDRATION','SEVERE (early)','Moderate-severe','Late onset'],
])
doc.add_paragraph()

ah('Signs of Strangulation — Surgical Emergency Indicators', level=2, color=(0x2E,0x75,0xB6))
ap('These signs mandate IMMEDIATE SURGERY without delay. Source: Bailey & Love 28th Ed., p. 1406.', italic=True, color=(0x70,0x70,0x70), size=9)
at(['Sign of Strangulation','Detail'],
[
    ['CONTINUOUS / CONSTANT PAIN (vs colicky)','Loss of colicky character; pain becomes CONSTANT and SEVERE = bowel ischaemia; peritonism developing'],
    ['PYREXIA + TACHYCARDIA','Temperature >38°C + HR >100 = systemic sepsis from bacterial translocation / bowel gangrene'],
    ['PERITONISM (guarding + rigidity + rebound)','Parietal peritoneum irritated by transmural bacterial translocation or free perforation → generalised peritonitis'],
    ['SHOCK (hypotension + pallor + cold peripheries)','Hypovolaemia (third-space fluid loss) + septicaemia (gram-negative bacteraemia)'],
    ['LOCALISED TENDERNESS / ERYTHEMA OVER HERNIA','Tender, irreducible hernia = STRANGULATION; overlying skin erythema = late sign = bowel already necrotic'],
    ['BLOODY DIARRHOEA / BLOODY PR DISCHARGE','Mucosal ischaemia → haemorrhagic infarction → bloody stool; intussusception = "redcurrant jelly" stool'],
    ['FEVER + LEUCOCYTOSIS','WBC >15,000/mm³ + temperature = strangulation until proven otherwise'],
])
doc.add_paragraph()

ah('Special Signs', level=2, color=(0x2E,0x75,0xB6))
at(['Sign','Condition','Description'],
[
    ['HOWSHIP-ROMBERG SIGN','Obturator hernia (obstructs small bowel)','Pain in medial thigh / inner aspect of knee on internal rotation of the hip — obturator nerve compression by herniated bowel'],
    ['DANCE\'S SIGN','Intussusception','Empty right iliac fossa (RIF) on palpation — ileocaecal intussusception drags caecum out of RIF; absent caecal gas on AXR'],
    ['SAUSAGE-SHAPED MASS (RUQ or transverse)','Intussusception','Palpable sausage-shaped, curved mass in RUQ (ileocolic type); "target sign" on USS'],
    ['"REDCURRANT JELLY" STOOL','Intussusception (late)','Blood + mucus per rectum from mucosal ischaemia; late sign (bowel ischaemia established)'],
    ['VISIBLE PERISTALSIS','SBO (thin abdominal wall — malnourished/elderly)','Dilated small bowel contractions visible through abdominal wall — "ladder pattern"'],
    ['HERNIAL ORIFICES','External hernia obstruction','Always EXAMINE ALL HERNIAL ORIFICES (inguinal, femoral, umbilical, incisional, obturator, sciatic) in intestinal obstruction — femoral hernia often missed'],
])
doc.add_paragraph()

# ─── SECTION 6: INVESTIGATIONS ───
ah('6. INVESTIGATIONS', level=1)
ap('ALWAYS follow: bloods → AXR → CT (the new gold standard). Never delay surgery for investigations if strangulation is clinically obvious.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

ah('Blood Tests', level=2, color=(0x2E,0x75,0xB6))
at(['Test','Findings + Significance'],
[
    ['FBC','WBC ↑ (leucocytosis + neutrophilia) = infection / strangulation; haemoconcentration (raised haematocrit from dehydration); anaemia (malignancy)'],
    ['UREA + CREATININE + ELECTROLYTES','Raised urea + creatinine = pre-renal uraemia (dehydration + third-space loss); HYPOKALAEMIA (from vomiting + fluid loss) — must correct before surgery; hyponatraemia; chloride loss in high SBO'],
    ['SERUM AMYLASE','Mildly elevated in any acute abdominal crisis; very high = pancreatitis (exclude as cause of ileus)'],
    ['SERUM LACTATE','ELEVATED lactate (>2 mmol/L) = intestinal ischaemia / strangulation until proven otherwise; metabolic acidosis on ABG'],
    ['BLOOD CULTURES','If pyrexia/sepsis — before antibiotics; gram-negative bacteraemia (E. coli, Klebsiella, Enterococcus, Bacteroides)'],
    ['CLOTTING + GROUP/SAVE','Before surgery; coagulopathy in septic patients; transfusion preparation'],
    ['LFTs + ALBUMIN','Baseline; hypoalbuminaemia in malnutrition (malignancy, chronic obstruction)'],
    ['ABG (arterial blood gas)','Metabolic alkalosis (high SBO with profuse vomiting — loss of HCl); metabolic acidosis (strangulation — raised lactate); hypoxia if aspiration'],
])
doc.add_paragraph()

ah('Imaging', level=2, color=(0x2E,0x75,0xB6))
at(['Investigation','Role / Key X-ray Signs'],
[
    ['ERECT CHEST X-RAY (CXR) — FIRST FILM','Pneumoperitoneum (free air under diaphragm) = PERFORATION → emergency surgery; baseline pulmonary status; exclude aspiration pneumonia'],
    ['SUPINE + ERECT ABDOMINAL X-RAY (AXR) — FIRST LINE','SUPINE: dilated bowel loops; bowel gas pattern; free gas. ERECT: AIR-FLUID LEVELS (multiple horizontal fluid-air interfaces at different levels in same bowel loop = MECHANICAL obstruction). DIAGNOSIS on AXR in ~70% of cases. ALWAYS order ERECT + SUPINE together.'],
    ['AXR SIGNS OF SBO','(1) Dilated small bowel loops (>3 cm central — "step-ladder" pattern); (2) Valvulae conniventes / plicae circulares (complete transverse folds across FULL width of lumen — SMALL BOWEL); (3) Central abdominal location; (4) Multiple air-fluid levels at DIFFERENT HEIGHTS in same loop (mechanical); (5) Absent distal gas'],
    ['AXR SIGNS OF LBO','(1) Peripheral / frame distribution; (2) HAUSTRAL FOLDS (incomplete, thumb-print folds crossing only PART of lumen — COLON); (3) Large calibre dilatation (>6 cm colon; >9 cm caecum); (4) "Coffee bean" sign = SIGMOID VOLVULUS (inverted U-loop, haustrum-free, apex in LUQ/RUQ, medial wall crease)'],
    ['AXR GALLSTONE ILEUS TRIAD (Rigler\'s triad)','(1) Air-fluid levels (SBO); (2) PNEUMOBILIA (air in biliary tree from cholecystoenteric fistula); (3) Ectopic calcified gallstone (usually RIF / terminal ileum position); CLASSIC TRIAD diagnostic of gallstone ileus'],
    ['CT ABDOMEN + PELVIS (with IV + oral contrast) — GOLD STANDARD','CT has replaced all other investigations as GOLD STANDARD for intestinal obstruction. Findings: (1) TRANSITION ZONE (from dilated to collapsed bowel = site of obstruction); (2) Cause of obstruction (adhesive band vs mass vs hernia vs volvulus — "whirl sign"); (3) Signs of STRANGULATION: mesenteric oedema + haziness; "target sign" (bowel wall thickening + mucosal enhancement / lack of enhancement); mesenteric fat stranding; free fluid; free air (perforation); (4) CLOSED-LOOP: U or C-shaped distended loop with convergence of mesentery; (5) "Small bowel faeces sign" (particulate matter in small bowel = transition zone marker)'],
    ['USS ABDOMEN','Role: (1) Intussusception in children — "target sign" / "doughnut sign" (concentric rings on transverse USS); "pseudokidney sign" on longitudinal view; (2) Confirm dilated bowel loops; (3) Free fluid in strangulation; LIMITED for definitive obstruction diagnosis'],
    ['WATER-SOLUBLE CONTRAST FOLLOW-THROUGH (GASTROGRAFIN / HYPAQUE)','Via NG tube: used in adhesive SBO — if contrast reaches colon within 24 hours = CONSERVATIVE MANAGEMENT safe; failure = surgery. BOTH therapeutic (promotes resolution of ileus) + diagnostic. DO NOT use barium if perforation suspected (barium peritonitis is lethal).'],
    ['CONTRAST ENEMA','Gastrografin enema: for LBO — confirms level + cause; therapeutic in volvulus (distended sigmoid) + meconium ileus (N-acetylcysteine enema)'],
])
doc.add_paragraph()

# ─── SECTION 7: MANAGEMENT ───
ah('7. MANAGEMENT', level=1)
ap('DRIP and SUCK = Foundation of conservative management. ASSESS for strangulation constantly. If in doubt, OPERATE.', bold=True, color=(0xC0,0x00,0x00))

ah('A. INITIAL RESUSCITATION (ALL patients)', level=2, color=(0x2E,0x75,0xB6))
at(['Step','Action'],
[
    ['IV ACCESS + FLUIDS','2 large-bore IV cannulae; IV Hartmann\'s solution or normal saline (correct hypovolaemia + electrolyte losses); catheterise + monitor hourly urine output (target >0.5 mL/kg/hr)'],
    ['NASOGASTRIC (NG) TUBE — "SUCK"','Ryle\'s tube (non-vented) or Salem sump (vented); free drainage + 4-hourly aspiration; DECOMPRESSES proximal bowel; reduces vomiting; aspiration risk prevention before anaesthesia'],
    ['ELECTROLYTE CORRECTION','IV KCl (potassium replacement — minimum 20 mmol/hr); monitor Na, K, Cl, bicarbonate; correct metabolic alkalosis (replace Cl⁻ losses in high SBO)'],
    ['ANTIBIOTICS','IV broad-spectrum (piperacillin-tazobactam or cefuroxime + metronidazole) if strangulation/perforation suspected or at surgical preparation; continues post-operatively if strangulated bowel found'],
    ['ANALGESIA','IV morphine or opioid — does NOT mask signs; adequate analgesia is humane + reduces distress; use cautiously (ileus risk)'],
    ['INVESTIGATIONS','Blood tests + AXR + CT as above; monitor clinically every 2 hours in conservative management'],
])
doc.add_paragraph()

ah('B. CONSERVATIVE (NON-OPERATIVE) MANAGEMENT — Adhesive SBO', level=2, color=(0x2E,0x75,0xB6))
ap('"Drip and Suck" for up to 72 hours in ADHESIVE SBO without signs of strangulation. Source: Bailey & Love 28th Ed., p. 1406-1407.', italic=True, color=(0x70,0x70,0x70), size=9)
at(['Criteria','Conservative Management Appropriate'],
[
    ['PATIENT SELECTION','Adhesive SBO (known previous surgery) + PARTIAL obstruction + NO strangulation signs + NO peritonism'],
    ['MONITORING','Strict hourly observations (pulse, BP, temperature, UO); serial abdominal examinations every 2 hours; daily AXR'],
    ['GASTROGRAFIN CHALLENGE (now standard)','Gastrografin 100 mL via NG tube → AXR at 24 hours. If contrast visible in colon = conservative management likely to succeed. If no contrast in colon at 24 hours = surgery. Has THERAPEUTIC effect (hyperosmolar agent draws fluid into bowel → stimulates peristalsis)'],
    ['DURATION','Maximum 72 hours (classical teaching: "the sun should not rise and set twice on an unresolved obstruction — Bailey & Love); after 72 hours without resolution → surgery'],
    ['INDICATIONS TO CONVERT TO SURGERY','Strangulation signs (fever, tachycardia, peritonism, rising WBC, rising lactate); pain changing to constant; clinical deterioration; failure of conservative management at 72 hours; closed-loop obstruction on CT'],
])
doc.add_paragraph()

ah('C. SURGICAL MANAGEMENT — INDICATIONS FOR EARLY/URGENT SURGERY', level=2, color=(0x2E,0x75,0xB6))
at(['Indication for IMMEDIATE Surgery','Rationale'],
[
    ['STRANGULATION / BOWEL ISCHAEMIA','Prevent perforation + peritonitis; mortality doubles for each hour of delay after strangulation confirmed'],
    ['OBSTRUCTED EXTERNAL HERNIA','Cannot reduce (hernia neck tight) → strangulation inevitable; urgent surgery'],
    ['CLOSED-LOOP OBSTRUCTION (CT diagnosed)','Volvulus / LBO with competent IC valve — no proximal decompression possible; rapid progression to perforation'],
    ['PERFORATION (free air on CXR/CT)','Emergency laparotomy'],
    ['PREVIOUSLY UNOPERATED ABDOMEN (de novo obstruction)','No adhesions to explain obstruction → likely mechanical cause requiring surgery; also no adhesiolysis to resolve spontaneously'],
    ['FAILED CONSERVATIVE MANAGEMENT (>72 hours)','Adhesive SBO not resolving = underlying cause needing surgery'],
    ['LBO from MALIGNANCY','Requires resection ± stent (see below)'],
])
doc.add_paragraph()

ah('D. SURGICAL PROCEDURES', level=2, color=(0x2E,0x75,0xB6))
at(['Cause','Surgical Procedure'],
[
    ['ADHESIVE SBO','ADHESIOLYSIS (division of adhesive bands): sharp scissors/diathermy; MIDLINE LAPAROTOMY for unknown site (allows full exploration); assess bowel viability (Pink + glistening + peristalsis + bleeding at cut edge = viable). Resect + primary anastomosis if viable doubt. "Second look" laparotomy at 24-48 hours if marginal viability.'],
    ['OBSTRUCTED INGUINAL / FEMORAL HERNIA','HERNIOTOMY + HERNIORRHAPHY (Bassini/Shouldice/mesh repair); if strangulated: assess bowel viability; RESECT non-viable bowel + primary small bowel anastomosis; femoral: Lockwood (below inguinal ligament), Lotheissen (through inguinal canal) or McEvedy (high approach above inguinal ligament — best access for strangulated bowel)'],
    ['GALLSTONE ILEUS','ENTEROLITHOTOMY (remove stone via enterotomy at site of impaction at terminal ileum) + close enterotomy; do NOT repair fistula at same sitting (high-risk inflamed field); elective cholecystectomy + fistula repair later (if fit patient)'],
    ['INTUSSUSCEPTION (children)','(1) PNEUMATIC REDUCTION (air enema) or HYDROSTATIC REDUCTION (saline enema under USS guidance) — first-line; SUCCESS in 60-90% in children without peritonitis; (2) SURGERY if: peritonitis / perforation / failed enema / recurrence >3 times; (3) OPERATIVE REDUCTION: "milking" technique — push from distal end (NOT pull from proximal); (4) RESECTION if: irreducible / non-viable / lead point found'],
    ['INTUSSUSCEPTION (adults)','SURGERY — always resect (lead point must be identified and removed; malignancy most common); right hemicolectomy for ileocolic type'],
    ['SIGMOID VOLVULUS','(1) FLEXIBLE SIGMOIDOSCOPY / RIGID SIGMOIDOSCOPE — initial non-operative decompression + flatus tube placement (left 2-5 days); success in 70-80%; (2) If ischaemia/necrosis on scope: URGENT LAPAROTOMY; (3) After decompression: ELECTIVE HARTMANN\'S PROCEDURE or sigmoid resection + anastomosis to prevent recurrence (high recurrence rate 50-90% without resection — Bailey & Love)'],
    ['CAECAL VOLVULUS','NO successful endoscopic decompression (unlike sigmoid); URGENT SURGERY: (1) DETORSION alone (high recurrence); (2) CAECOPEXY (fix caecum to lateral peritoneum); (3) RIGHT HEMICOLECTOMY (definitive; preferred if bowel viable); (4) HARTMANN\'S if bowel non-viable'],
    ['LBO from CARCINOMA (obstructing)','(1) SELF-EXPANDING METAL STENT (SEMS) endoscopically — "bridge to surgery" (ESGE recommended) or palliation; (2) ONE-STAGE resection (right hemicolectomy for right colon; Hartmann\'s for left colon — safer than primary anastomosis in obstructed colon); (3) ON-TABLE LAVAGE + primary anastomosis (for left-sided colonic obstruction in fit patients at specialist centres); (4) SUBTOTAL COLECTOMY + ileorectal anastomosis'],
    ['PARALYTIC ILEUS','CONSERVATIVE: NG decompression + IV fluids + electrolyte correction (especially K+); treat underlying cause (peritonitis, pancreatitis, pneumonia); ambulation; early feeding; neostigmine IV (0.5 mg IV over 3-5 min with monitoring) or colonoscopic decompression for Ogilvie\'s syndrome'],
    ['OGILVIE\'S SYNDROME (Colonic pseudo-obstruction)','(1) Correct electrolytes + stop causative drugs; (2) NEOSTIGMINE 2 mg IV slow bolus (highly effective ~80%; contraindicated in bradycardia/asthma; atropine on standby); (3) COLONOSCOPIC DECOMPRESSION (mechanical decompression; success 70-80%; 40% recurrence — leave decompression tube); (4) Surgery only if: caecum >12 cm (perforation risk) + all else fails'],
    ['ADHESION PREVENTION — RECENT ADVANCE','HYALURONATE-CARBOXYMETHYLCELLULOSE (SEPRAFILM) bioresorbable membrane placed over bowel at laparotomy reduces adhesion formation; reduces SBO episodes post-operatively'],
])
doc.add_paragraph()

ah('E. ASSESSING BOWEL VIABILITY (Intraoperative)', level=2, color=(0x2E,0x75,0xB6))
at(['Assessment','Viable Bowel','Non-viable / Doubtful Bowel'],
[
    ['COLOUR','Pink / normal','Grey / black / green'],
    ['SHEEN','Glistening serosa','Dull, opaque serosa'],
    ['PERISTALSIS','Present (responds to stimulation)','Absent'],
    ['EDGE BLEEDING','Bleeds at cut edge','No bleeding at cut edge'],
    ['MESENTERIC PULSATION','Pulsatile mesenteric vessels','Absent pulsation'],
    ['MANAGEMENT','Leave in situ','RESECT with 5 cm margins + primary anastomosis (small bowel); OR: place in warm packs 5 minutes → reassess. SECOND LOOK LAPAROTOMY at 24-48 hours if any doubt (prefer over anastomotic breakdown)'],
])
doc.add_paragraph()

# ─── SECTION 8: VOLVULUS ───
ah('8. VOLVULUS — DETAILED NOTE', level=1)
ap('DEFINITION (Source: Bailey & Love 28th Ed., p. 1401): A volvulus is a twisting or axial rotation of a portion of bowel about its mesentery. >180° torsion = luminal obstruction; >360° torsion = vascular occlusion in mesentery → strangulation.', italic=True)
doc.add_paragraph()
at(['Feature','SIGMOID VOLVULUS','CAECAL VOLVULUS'],
[
    ['PATIENT PROFILE','Elderly, institutionalised; psychiatric inpatients; constipated; high-fibre diet (West Africa = young adults); male > female','Younger patients (30-60 yrs); females slightly more common; history of hypermobile caecum'],
    ['ANATOMY','Elongated sigmoid loop + narrow posterior mesenteric attachment + loaded pelvic colon → twists on its own axis','Mobile caecum (failure of normal peritoneal fixation in embryological development) → twists axially or inverts into LUQ'],
    ['DEGREE OF ROTATION','Usually >360° → vascular compromise','180-360°'],
    ['CLINICAL FEATURES','Massive abdominal distension (asymmetric, left-sided); mild pain (if ischaemia: pain becomes severe); history of previous episodes + spontaneous resolution','Severe colicky pain + distension + vomiting; acute presentation'],
    ['X-RAY SIGN','Classic "COFFEE BEAN SIGN" or "INVERTED U-LOOP": massively dilated haustrum-free sigmoid loop in U shape; apex points to RUQ / LUQ; medial walls fused = "crease of bean"; liver overlap sign; left flank overlap sign; pelvic overlap sign — Source: Grainger & Allison Radiology p. 1089-1090','Distended caecum often in LUQ (inverted); single large air-fluid level; small bowel distension; difficult to diagnose on plain X-ray — CT is better'],
    ['CT SIGN','WHIRL SIGN (twisted mesentery + mesenteric vessels); BIRD OF PREY SIGN (smooth tapering at torsion point); dilated haustrum-free sigmoid loop','Whirl sign; distended caecum; transition point at RIF'],
    ['INITIAL MANAGEMENT','NON-OPERATIVE: rigid sigmoidoscope / flexible colonoscope + flatus tube insertion (success 70-80%); assess mucosal viability directly; ERECT on passage of flatus tube; leave tube 2-5 days; if ischaemia/necrosis on scope → URGENT SURGERY','URGENT SURGERY always (no reliable non-operative approach); right hemicolectomy preferred'],
    ['DEFINITIVE SURGERY','ELECTIVE sigmoid resection (Hartmann\'s or resection + anastomosis) to prevent 50-90% recurrence after decompression','Right hemicolectomy (definitive + removes ischaemic/at-risk bowel); caecopexy alone has high recurrence; detorsion alone inadequate'],
])
doc.add_paragraph()

# ─── SECTION 9: INTUSSUSCEPTION ───
ah('9. INTUSSUSCEPTION — DETAILED NOTE', level=1)
ap('DEFINITION: Intussusception is the telescoping (invagination) of one part of the bowel (intussusceptum) into the lumen of the immediately adjoining bowel (intussuscipiens). The mesentery is also drawn in with the bowel, causing venous obstruction → mucosal ischaemia → bloody mucus discharge ("redcurrant jelly" stool). Source: Bailey & Love 28th Ed., p. 1399-1401, Table 78.2.', italic=True)
doc.add_paragraph()
at(['Feature','Children (<2 years)','Adults (>40 years)'],
[
    ['INCIDENCE','Common; MOST COMMON cause of acute intestinal obstruction in 3-12 month age group','Rare; always suspect LEAD POINT (malignancy in 60%)'],
    ['CAUSE','IDIOPATHIC in 90% (viral lymphoid hyperplasia of Peyer\'s patches → mesenteric lymphadenopathy acts as lead point); Lead point in 10% (Meckel\'s diverticulum, duplication cyst, polyp, lymphoma)','Lead point ALWAYS found: polyp, carcinoma, Meckel\'s, lipoma, lymphoma; MUST resect'],
    ['TYPE (RE Gross classification)','ILEOCOLIC most common (77% — Source: Bailey & Love Table 78.2); Ileocolic: 77%; Ileoileocolic: 12%; Ileoileal: 5%; Colocolic: 2%','Usually small bowel (ileoileal) or ileocolic'],
    ['CLINICAL FEATURES','Triad: (1) Episodic screaming attacks (colicky pain — intermittent); (2) Vomiting; (3) Palpable SAUSAGE-SHAPED mass (RUQ / transverse); Dance\'s sign (empty RIF); "Redcurrant jelly" stool (LATE — blood + mucus per rectum when mucosal ischaemia established)','Vague colicky abdominal pain; mass; obstruction'],
    ['USS FINDINGS','TARGET SIGN (transverse) = concentric rings of bowel (most useful diagnostic); PSEUDOKIDNEY SIGN (longitudinal); sensitivity 85-95%','CT: "target" or "sausage" soft tissue mass with layering; mesenteric vessels visible inside bowel lumen — Bailey & Love p. 7370'],
    ['TREATMENT','(1) PNEUMATIC REDUCTION (air enema) / HYDROSTATIC REDUCTION (saline enema) under USS + fluoroscopy — first-line (success 60-90%); (2) Surgery if: peritonitis / perforation / 3 failed enemas; Manual reduction by "milking" (push from distal — do NOT pull from proximal)','ALWAYS surgical resection — lead point must be found and removed; right hemicolectomy for ileocolic type'],
])
doc.add_paragraph()

# ─── SECTION 10: PSEUDO-OBSTRUCTION / OGILVIE ───
ah("10. PSEUDO-OBSTRUCTION — OGILVIE'S SYNDROME", level=1)
ap("DEFINITION: Acute colonic pseudo-obstruction (ACPO) = massive dilatation of the colon in the absence of a mechanical obstructing lesion. Described by Ogilvie (1948). Due to autonomic imbalance (excess sympathetic tone + reduced parasympathetic tone) → impaired colonic motility.", italic=True)
doc.add_paragraph()
at(['Feature','Details'],
[
    ['CAUSES / ASSOCIATIONS','Post-operative (especially orthopaedic — hip/spine surgery); severe medical illness (pneumonia, MI, sepsis, renal failure); trauma; neurological disease (Parkinson\'s, spinal cord injury); metabolic (hypokalaemia, hyponatraemia, hypothyroidism); medications (opioids, anticholinergics, calcium channel blockers); ICU patients'],
    ['CLINICAL FEATURES','Massive abdominal distension without colicky pain (painless or mild); constipation; nausea; NO signs of peritonism (absence distinguishes from mechanical obstruction); AXR: massive colonic gas from caecum to rectum (rectosigmoid also distended — unlike Hirschsprung\'s)'],
    ['RISK OF CAECAL PERFORATION','Caecal diameter >12 cm = high perforation risk (Laplace law); mortality from perforation = 40-50%'],
    ['INVESTIGATION','AXR + CT (to exclude mechanical obstruction + assess caecal diameter)'],
    ['MANAGEMENT STEPS','(1) Treat underlying cause + CORRECT ELECTROLYTES (especially K+, Mg²+); (2) STOP causative drugs (opioids, anticholinergics); (3) Ambulate + position changes (knee-chest position helps); (4) NG tube; (5) NEOSTIGMINE 2 mg IV slow bolus (acetylcholinesterase inhibitor → increases parasympathetic tone → colonic contraction; 80% response; monitor for bradycardia/bronchospasm — atropine on standby; contraindicated in bradycardia, asthma, mechanical obstruction); (6) COLONOSCOPIC DECOMPRESSION if neostigmine fails (70-80% success; leave decompression tube to prevent recurrence); (7) SURGERY (caecostomy or laparotomy) if caecum >12 cm + all else fails'],
])
doc.add_paragraph()

# ─── SECTION 11: GALLSTONE ILEUS ───
ah('11. GALLSTONE ILEUS — SPECIAL TOPIC', level=1)
ap('Gallstone ileus = mechanical SBO caused by a large gallstone (usually >2.5 cm) that has eroded through the GB wall into the duodenum (cholecystoduodenal fistula), passed through the intestine and impacted at the TERMINAL ILEUM (narrowest part of small bowel). Accounts for 1-4% of all SBO; 25% of SBO in elderly women without previous surgery.', italic=True)
doc.add_paragraph()
ap("RIGLER'S TRIAD (classic AXR diagnosis):", bold=True, color=(0x1F,0x4E,0x79))
ab('(1) Air-fluid levels of SBO')
ab('(2) PNEUMOBILIA — air in biliary tree (from fistula) — PATHOGNOMONIC')
ab('(3) ECTOPIC CALCIFIED GALLSTONE (visible in RIF / terminal ileum position) — only 50% of gallstones are radio-opaque')
ap('TREATMENT: ENTEROLITHOTOMY via enterotomy at impaction site (push stone proximally to wider segment then enterotomy + extract); do NOT repair cholecystoduodenal fistula at same sitting (inflamed field + elderly patient = dangerous); elective cholecystectomy + fistula repair at 6 weeks if patient fit.', bold=True, color=(0xC0,0x00,0x00))
doc.add_paragraph()

# ─── SECTION 12: RECENT ADVANCES ───
ah('12. RECENT ADVANCES', level=1)
advances=[
    'COLONIC STENTING (SEMS) for malignant LBO: ESGE (2014) recommends SEMS as "bridge to surgery" for left-sided obstructing colorectal cancer — allows elective one-stage resection with anastomosis (vs emergency Hartmann\'s); also palliative in advanced/metastatic disease. Avoids stoma in ~80% of patients in fit patients with resectable disease.',
    'GASTROGRAFIN CHALLENGE for adhesive SBO: hyperosmolar agent draws fluid into bowel lumen → therapeutic (promotes resolution of ileus) + diagnostic (contrast in colon at 24 hours = conservative management will succeed). Reduces need for surgery in adhesive SBO by 50% (Cochrane meta-analysis).',
    'LAPAROSCOPIC ADHESIOLYSIS: now feasible for adhesive SBO at experienced centres; lower wound complications + faster recovery vs open; not appropriate for multiple recurrences or matted adhesions.',
    'SMALL BOWEL CAPSULE ENDOSCOPY: for small bowel tumours causing chronic/subacute obstruction; non-invasive detection of Crohn\'s strictures, tumours, vascular lesions.',
    'SEPRAFILM (Hyaluronate-Carboxymethylcellulose): bioresorbable adhesion-prevention membrane; placed over anastomoses + bowel surfaces at laparotomy; reduces incidence of adhesion-related SBO by ~40%.',
    'CT SCORING SYSTEMS for strangulation: Closed-loop obstruction scoring on CT (AAST grade); "target sign" + mesenteric oedema + "whirl sign" on CT now guide surgical urgency with >90% sensitivity for strangulation.',
    'WATER-SOLUBLE CONTRAST ENEMA for LBO: CT has replaced contrast enema for diagnosis of LBO; CT identifies level + cause + vascular involvement in one study.',
    'NEOSTIGMINE for Ogilvie\'s syndrome: IV neostigmine 2 mg slow bolus; ~80% response rate; now first-line medical treatment before colonoscopic decompression (Ponec et al., NEJM 1999 RCT).',
    'LONG INTESTINAL DECOMPRESSION TUBE: transnasal long tube (Cantor tube / Miller-Abbott tube / Dennis tube) advanced into small bowel for adhesive SBO not responding to NG decompression alone; allows targeted small bowel decompression; used in Japan + some European centres.',
    'ERAS (Enhanced Recovery After Surgery) post bowel resection: early feeding + mobilisation + fluid restriction reduces post-operative ileus duration significantly.',
]
for a in advances: ab(a)
doc.add_paragraph()

# ─── SECTION 13: SCORING GUIDE ───
ah("13. EXAMINER'S SCORING GUIDE — 30 Marks", level=1)
at(['Section','Marks'],
[
    ['Definition + systematic classification (mechanical vs functional; simple vs strangulated vs closed-loop; SBO vs LBO; anatomical site table)','4'],
    ['Causes: SBO vs LBO table with ADHESIONS / hernia / malignancy / volvulus / intussusception / India-specific (TB, Ascaris)','4'],
    ['Pathophysiology (fluid/gas accumulation, vomiting, bacterial overgrowth, strangulation mechanism, electrolyte imbalance, closed-loop)','3'],
    ['Clinical features (4 cardinal features; SBO vs LBO comparison table; signs of strangulation; special signs — Howship-Romberg, Dance\'s, sausage mass)','4'],
    ['Investigations (bloods + AXR signs SBO/LBO + Rigler\'s triad + CT gold standard + USS for intussusception + Gastrografin challenge)','4'],
    ['Management: resuscitation (drip + suck) + conservative management (72 hours, Gastrografin) + indications for surgery','3'],
    ['Surgical procedures (adhesiolysis, hernia repair, volvulus management, intussusception reduction, LBO stenting + Hartmann\'s, bowel viability assessment)','4'],
    ['Special topics: Volvulus (sigmoid vs caecal — detailed); Intussusception (children vs adults); Ogilvie\'s syndrome; Gallstone ileus (Rigler\'s triad)','3'],
    ['Recent advances (SEMS, Gastrografin challenge evidence, laparoscopic adhesiolysis, neostigmine for Ogilvie\'s, Seprafilm)','1'],
    ['TOTAL','30'],
])
doc.add_paragraph()

ah('Mark-Winning Discriminators', level=2, color=(0x2E,0x75,0xB6))
tips=[
    'FEMORAL HERNIA has the HIGHEST strangulation rate of all external hernias (40%) — because of the narrow, rigid fibrous femoral ring. Always examine femoral orifice in any SBO patient.',
    'ALWAYS EXAMINE ALL HERNIAL ORIFICES in intestinal obstruction — femoral hernia is easily missed (especially in obese women).',
    'Colicky pain every 3-5 min = HIGH SBO (jejunum); every 10-15 min = LOW SBO (ileum); every 15-20 min = LBO (colon).',
    'Vomiting: EARLY + bilious = HIGH SBO; LATE + FAECULENT = LOW SBO or LBO (faeculent = bacterial fermentation of stagnant bowel contents).',
    'Distension: MINIMAL in high SBO; CENTRAL in SBO; PERIPHERAL / FRAME in LBO.',
    'Constipation EARLY + to BOTH flatus + faeces = LBO; Late constipation = SBO.',
    'Small bowel X-ray: VALVULAE CONNIVENTES (complete folds across FULL lumen width); Large bowel: HAUSTRAL FOLDS (incomplete, only cross PART of lumen).',
    'RIGLER\'S TRIAD for gallstone ileus: SBO + PNEUMOBILIA (air in biliary tree — pathognomonic) + Ectopic gallstone on AXR.',
    'COFFEE BEAN SIGN (sigmoid volvulus): inverted U-loop; massively dilated haustrum-free sigmoid colon; apex in RUQ; medial walls fused = bean crease; no rectal gas. Source: Grainger & Allison Radiology p. 1089.',
    'Sigmoid volvulus INITIAL treatment = flexible colonoscopy + flatus tube insertion (NON-OPERATIVE decompression); only if ischaemia → urgent surgery.',
    'Caecal volvulus = ALWAYS urgent surgery (right hemicolectomy); no endoscopic option (unlike sigmoid).',
    'Volvulus mechanism (Source: Bailey & Love p. 1401): >180° torsion = luminal obstruction; >360° torsion = VASCULAR occlusion.',
    'Intussusception in CHILDREN: IDIOPATHIC (90%); ileocolic most common (77% — RE Gross); treat with pneumatic/hydrostatic reduction first.',
    'Intussusception in ADULTS: ALWAYS has a LEAD POINT (malignancy 60%); treat by surgical resection.',
    '"Redcurrant jelly" stool = intussusception (blood + mucus = mucosal ischaemia; LATE sign).',
    'Target sign on USS = intussusception (concentric rings); Target sign on CT = strangulated bowel (bowel wall thickening + decreased enhancement).',
    'NEOSTIGMINE 2 mg IV = first-line medical treatment for Ogilvie\'s syndrome (80% response); monitor for bradycardia + bronchospasm; atropine on standby.',
    'Caecal diameter >12 cm in Ogilvie\'s syndrome = imminent perforation risk → urgent decompression (colonoscopy or surgery).',
    'Gastrografin challenge in adhesive SBO: therapeutic + diagnostic; contrast in colon at 24 hours = surgery avoided; reduces operative rate ~50%.',
    'SEMS (self-expanding metal stent) = "bridge to surgery" for obstructing left-sided colon cancer; avoids emergency Hartmann\'s; allows elective one-stage resection + anastomosis.',
    'BOWEL VIABILITY: viable = pink + glistening + peristalsis + bleeds at cut edge; non-viable = grey/black + dull + no peristalsis + no bleeding → resect. Second-look laparotomy at 24-48 hours if doubt.',
    '"Drip and suck" = IV fluids + NG decompression = foundation of conservative SBO management.',
    'Bailey & Love classical teaching: "The Sun should not rise and set TWICE on an unresolved intestinal obstruction" = operate within 72 hours if conservative management fails.',
    'India-specific: Ileocaecal TB (hyperplastic form → most common cause of ileocaecal mass obstruction in India); Ascaris worm bolus (ileal obstruction from clumped worms — children).',
]
for t in tips: ab(t)
doc.add_paragraph()
ps=doc.add_paragraph()
rs=ps.add_run("Sources: Bailey & Love's Short Practice of Surgery 28th Ed. (Ch. 77, 78 p. 1397-1412) | Fischer's Mastery of Surgery 8th Ed. | Sabiston Textbook of Surgery 21st Ed. | Grainger & Allison's Diagnostic Radiology (Large-Bowel Obstruction, p. 1083-1097) | Current Surgical Therapy 14e | Schwartz's Principles of Surgery 11th Ed.")
rs.italic=True; rs.font.size=Pt(9); rs.font.color.rgb=RGBColor(0x70,0x70,0x70)

out='/tmp/workspace/ms-surgery-notes/Intestinal_Obstruction_30marks.docx'
doc.save(out)
print(f'Saved: {out}')